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THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

EDITED BY

I. MINIS HAYS, A.M., M.D.

NEW SERIES.
VOL. LXXXVI.

PHILADELPHIA:
HENRY C. LEA'S SON & CO.
1883.

69512

Entered according to the Act of Congress, in the year 1883, by

HENRY C. LEA'S SON & CO.,
in the Office of the Librarian of Congress. All rights reserved.

PHILADELPHIA :
COLLINS, PRINTER,

705 Jayne Street.

V.8G>

Med.

TO READERS AND CORRESPONDENTS.

All communications intended for insertion in the Original Department of this
Journal are only received for consideration with the distinct understanding that
they are sent for publication to this Journal alone, and that abstracts of them
shall only appear elsewhere subsequently, and with due credit. Gentlemen
favouring us with their communications are considered to be bound in honour to
a strict observance of this understanding.

Contributors who wish their articles to appear in the next number are requested
to forward them before the 1st of August.

Liberal compensation is made for all articles used. Extra copies, in pamphlet
form with cover, will be furnished to authors in lieu of compensation, provided
the request for them be made at the time the communication is sent to the Editor.

The following works have been received for review : —

Handbuch der Historisch-Geographischen Pathologie, von Dr. August Hirsch,
Zweite Abtheilung : Die Chronischen Infections- und Intoxications Kranheiten, Para-
sitare kranheiten, Infectiore Wund Kranheiten und Chronische Ernahrunganomalien.
Stuttgart, Ferdinand Enke, 1883. \

Officieller Katalog der Allgemeinen Deutschen Austellung auf dem Gebeite der
Hygiene und des Rettungswesens. Berlin, 1883.

Vormost zum Officillen Katalog der Hygiene. Austellung in Berlin, 1883.

Ueber den gegenwartigen Stand der internen Therapie und den therapeutischen
unterricht an der deutschen Hochschulen. Von Dr. M. Rossbach. Berlin, 1883.

Ueber die Taubheil bei hysterischer Hemiansesthesie. Von Herr Dr. G-. L. Wal-
ton. Berlin, 1883.

Ueber die Aenderungen der Leistemgsfahigkeit und der Enigbarkeit des ermiiden-
den Froschherzens. By Thomas J. Mays, M.D.

Uberdie Wirkungen der verdiinnten Luftauf den Organismus. Eine experimental
Untersuchung. Von Dr. A. Frankel und Dr. J. Geppert. Berlin. A. Hirschwald,
1883.

tiber Gelenksresektionen bei Caries. Von Prof. Dr. E. Albert. Wien, 1883.
Sur Quelques Causes de Maladies de l'Oreille. Par A. Ducau. Paris : Octave Doin,
1883.

De PEmploi de la Resorcine dans le traitement du chancre simple chez la Femme.
Par MM. les Drs. A. Leblond et Fissiaux. Paris : H. Lauwereyns, 1883.

Considerations suruncasde Fievre Typhoide compliques d'Arthrites et de Synovites
Purulentes Generalises. Par le Dr. Albert Robin. Paris, 1882.

Note sur une des causes de la Lithiase unique et oxalique chez les Enfants du Premier
Age. Par le Dr. Albert Robin. Paris, 1883.

De la Production de Phenol dans POrganisme considered au point de vue Physiolo-
gique et Clinique. Par le Dr. Albert Robin. Paris, 1882.

De l'Urine dans l'Hematurie des Calculus. Par le Dr. Albert Robin, Laureat de
l'Institut et de la Faculte de Melecine. Paris, 1878.

Introduction a l'Etude de l'Electrotonus des Nerfs chez l'Homme. Par Armand
de Watteville. Loudres : Ranken et Cie, 1883.

Discours Prononcee sur la Tombe de M. leProfesseur Lasegue. Par les Professeurs
Germain See, Potain, et MM. les Docteurs Legroux, Fernet, et Motch.

Manuel des Injections sous-cutanees. Par Bourneville, Medecin de Bicetre et
Bricon, M.D. Paris, 1883. Pp. xxxvi., 175. A. Delahaye So E. Lecrosnier,

Des Affections Cerebrales consecutives aux Lesions Non-traumatiques du Rocher et
de l'Appareil audatif. Par le Dr. Albert Robin. Paris : J. B. Bailliere, 1883.

Essai d'Urologie Clinique. La Fievre Typhoide. Par le Dr. Albert Robin. Paris :
J. B. Bailliere et Fils, 1883.

Traite des Fibres Bilieuses et Typhiques des Pays Chauds. Par le Dr. A, Corre,
Professeur Agrege a l'Ecole de Medecine Navale de Brest. Paris : O. Doin, 1883.

TO READERS AND CORRESPONDENTS.

De l'Excision du Goitre Parenehymateux, par le Dr. Paul Liebrecht, Assistant &,
'Universite de Liege. Bruxelles, 1883.

Chirurgie Orthopedique ; Lc§ons Cliniques Profeeees a l'H&pital des Enfants Malades.
Par Dr. L. A. De Saint-Germain, Chirurgien de l'Hopital des Enfants Malades. Re-
cueillies et Publies. Par la Dr. Pierre J. Mercier. Paris: J. B. Bailliere et Fils, 1883.

Pathology of Bronchitis, Catarrhal Pneumonia, Tubercle and allied Lesions of the
Human Lung. By D. J. Hamilton, M.B., F.R.C.S.E., F.R.S.E., Professor of Patho-
logical Anatomy, University of Aberdeen. London : Macrnillan & Co., 1883.

Transactions of the Obstetrical Society of London. Vol. XXIV. For the year 1882.
London : Longmans, Green & Co., 1883.

St. Bartholomew's Hospital Reports, 1882.

Observations on Lithotomy. Lithotrity, and the Early Detection of Stone in the
Bladder. With a Description of a new method of Tapping the Bladder. By Reginald
Harrison, F.R.C.S. London : J. & A.Churchill, 1883.

Transfusion ; Its History, Indications, and Modes of Application. By Chas. Eger-
ton Jennings, L.R.C.P. Lond., etc. London : Bailliere, Tindall & Cox, ISS'3.

Practical Lessons in Elementarv Physiology and Phvsiological Anatomy. For Schools
and Science Classes. By D. M'Alpine, F.C.S. London : Bailliere, Tindall & Cox, 1883.

On some of the Advances which have been made in Abdominal Surgery during the
last Decade. By James Whitson, M.D., etc.

Photography of Microscopic Sections. By James Whitson, M.D.

Notes of a case of Enteric Fever which had two Relapses, with an unusual prolonga-
tion of the Interval between the first and second attacks. By Rob't H. Forrest, M.D.

Medical Education, Character, and Conduct. Introductory Addresses delivered to
the Students of Medicine in Edinburgh and Glasgow, 18r>5-18(>6-1882. By W. T.
Gairdner, M.D., Professor of Medicine in the University of Glasgow. Glasgow, 1883.

Sanitary Contrasts of the British and French Armies during the Crimean War. By
Surgeon-General T. Longmore, C.B. London : Charles Griffin & Co., 1883.

Nitrite of Sodium in the Treatment of Angina Pectoris. By Matthew Hat, M.D.,
Demonstrator of Practical Materia Medica in the University of Edinburgh, 1883.

Abdominal Hernia and its consequences, with the principles of its active treatment.
By Rushton Parker, B.S., F.R.C.S., etc. Liverpool, 1883.

Proceedings of the N. W. Provinces and Oudh Branch of the British Medical Associ-
ation, January, February, March, 1883.

The Principles and Practice of Medical Jurisprudence. By the late Alfred Swaine
Taylor, M.D., F.R.S., Fellow of the Royal College of Physicians of London. Third
edition. Edited by Thomas Stevenson, M.D., F.R.C.P. Loud., Lect. Med. Jurispru-
dence, at Guy's Hospital, etc. 2 Vols. Philadelphia : Henry C. Lea's Son &Co., 1883.

A Practical Treatise on Impotence, Sterility, and allied Disorders of the Male Sexual
Organs. By Samuel W. Gross, A.M., M.D., Professor of the Principles of Surgery
and of Clinical Surgery in the Jefferson Medical College of Philadelphia. Second
edition, thoroughly revised. Philadelphia : Henry C. Lea's Son & Co., 1883.

Students' Guide to Diseases of the Eye. By EdVard Nettleship, F.R.C.S., Oph-
thalmic Surgeon to St. Thomas's Hospital, etc. Second American from the second re-
vised and enlarged English edition. With a chapter on Examination for Color Per-
ception. By Wm. Thomson, M.D., Professor of Ophthalmology in Jefferson Medical
College. Philadelphia : Henry C. Lea's Son & Co., 1883.

Allen's Human Anatomy^ By Harrison Allen, M.D., Professor of Physiology in
the University of Pennsylvania. Section IV. Arteries, Veins, and Lymphatics. Phila-
delphia : Henry C. Lea's Son & Co., 1883.

Manual of Auscultation and Percussion, embracing the Physical Diagnosis of Dis-
eases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M.D. ,
Professor of Principles and Practice of Medicine in the Bellevue Hospital Medical Col-
lege. Third edition, revised. Philadelphia : Henry C. Lea's Son & Co.. ISSo.

Hand-book of Diagnosis and Treatment of Diseases of the Throat, Nose, and Naso-
pharynx. By Carl Seiler, M.D., Lecturer on Laryngoscopy at the University of
Pennsylvania, etc. Second edition, thoroughly I'evised and enlarged. With seventy-
seven illustrations. Philadelphia ; Henry C. Lea's Son & Co., 1883.

Proposed Ordinance and Rules and Regulations for regulating the Plumbing, House
Drainage, Registration, and Licensing of Plumbers in the City of Philadelphia. As re-
ported by the Committee of twent.y-one. Philadelphia: P. Blakiston, Son & Co., 1883.

Manual of Practical Hygiene. By Edmund A. Parkes, M.D., F.R.S., Professor of
Military Hygiene in the Army Medical School, London, etc. Edited by P. S. B. Fran-
gois de Chaumont, M.D., F.R.S., etc. Sixth edition. Philadelphia: P. Blakiston,
Son & Co., 1883.

Practitioners Ready Reference Book. By Richard J. Dunglison, A.M., M.D., etc.
Third edition. Philadelphia : P. Blakiston, Son & Co., 1883.

Lectures on Diseases of the Nervous System, delivered at Guy's Hospital. By
Samuel Wilks, M.D., F.R.S. Second edition. Philadelphia : P. Blakiston. Son &
Co., 1883

TO READERS AND CORRESPONDENTS.

The Dispensatory of the United States of America. By Dr. Geo. B. Wood and Dr.
Franklin Bache. Fifteenth edtion. By H. C. Wood, M.D., Joseph, P. Remington,
Ph.G., and Samuel P. Sadtler, Ph.G-. Philadelphia : J. B. Lippincott & Co. 1883.

Lectures on Orthopedic Surgery aud Diseases of the Joints. By Lewis A. Sayke,
M.D., Professor of Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medi-
cal College, etc. Second edition. New York : D. Appleton & Co., 1883.

Treatise on Insanity in its Medical Relations. By William A. Hammond, M.D., etc.
8vo. New York : D. Appleton & Co., 1883.

A Treatise on Therapeutics, comprising Materia Medica and Toxicology. By H. C.
Wood. M.D., Prof, of Materia Medica and Therapeutics in the University of Pa. Fifth
edition, revised and enlarged. Philadelphia : J. B. Lippincott & Co., 1883.

Diseases of the Ovaries. By Lawson Tait, F.R.C.S. Fourth edition. New York :
Wm. Wood &> Co.. 1S83.

Manual of Gynecology. Bv D. Berry Hart, M.D., and A. H. Barbour, M.D.
2 Vols. New York : Wm. Wood & Co., 1S83.

Diagnosis of Ovarian Cysts. By Henry Jacques Garrigues, M.D. New York:
Wm. Wood & Co., 1883.

Index of the Practice of Medicine. Bv Wesley M. Carpenter, M.D. New York :
Wm. Wood & Co., 1883.

Diseases of Women. A Manual for Physicians and Students. By Heinrich Fritsch,
M.D, Professor of Gynecology iu the University of Halle. Translated by Isidor Furst.
New York : Wm. Wood & Co., 1883.

The Microscope and its Revelations. Bv William B. Carpenter, C.B., M.D.,
LL.D., F.R.S., etc. Sixth edition. 2 Vols.' New York : Wm. Wood & Co., 1883.

The International Encyclopaedia of Surgery. A Systematic Treatise on the Theory
and Practice of Surgery. Bv Authors of Various Nations. Edited by John Ashhurst,
Jr., M.D. Vol. 111. New York : Wm. Wood & Co., 1883.

Insanity : Its Causes and Prevention. By Henry Putnam Stearns, M.D., Superin-
tendent of Asylum for Insane, Hartford, Conn. New York : G. P. Putnam's Sons, 1883.

Brain Rest. By J. Leonard Corning, M.D. New York : G. P. Putnam's Sons, 1883.

Medical Essays. 1842-1882. By Oliver Wendell Holmes. Boston : Houghton,
Mifflin & Co., 1883.

Labor among Primitive Peoples. Showing the Development of the Obstetric Science
of to-day, from the natural and instinctive customs of all Races. By George J. En-
gelmann, A.M., M.D., Professor of Obstetrics in the Post-Graduate School of the
Missouri Medical College, etc. Second edition. St. Louis : J. H. Chambers & Co., 1883.

Bacteria or the Germ Theory of Disease. By Dr. H. Gradle, Prof, of Physiology,
Chicago Medical College. Chicago : W. T. Keener, 1883.

On the Relations of Micro-Organisms to Disease. By Wm.T. Belfield, M.D., Lecturer
on Pathology, etc., Rush Medical College, Chicago. Chicago : W. T. Keener, 1883.

The Medical and Surgical History of the War of the Rebellion. Part III. Volume
II. Surgical History. Prepared under the direction of Joseph K. Barnes, Surgeon-
General U. S. A. Bv George A. Otis, Sura-eon U. S. A. Washington, 1883.

The Gout in its Protean Aspects. By J. Milner Fothergill, M.D., M.R.C.P.
Detroit : George S. Davis, 1S83.

Heart Puncture and Heart Suture as Therapeutic Procedures. By John B. Ro-
berts, M.D., of Philadelphia.

The Clinical History, and exact Localization of Perinephric Abscess. By John B.
Roberts, M.D., of Philadelphia.

The Rational Treatment of Spasmodic Asthma. By Richard B. Faulkner, M.D.

Tubercular Cerebro-Spinal Meningitis. By J. T. Eskridge, M.D., Physician to St.
Mary's aud Jefferson College Hospitals.

Treatment of Chronic Nasal Catarrh. By J. Addison Stucky, M.D.

Observations on a Series of Fifteen Successful Cases of Ovariotomy. By O. O. Bur-
gess, M.D.

Symptoms and Diagnosis of Malaria in Children. By L. Emmet Holt, A.M., M.D.

Alcohol ; as a Food, a Medicine, a Poison, and as a Luxury. By Geo. C. Pitzer,
M.D. St. Louis, 1883.

Cancer of the Intestinal Tract : Operations for the removal of Malignant Strictures
of Pylorus and Intestines. Together with a brief review of the Historical Development
of Modern Abdominal Surgery. By Reuben A. Vance, M.D., etc., Cleveland, Ohio.

An Argument submitted to the Cuyahoga County Medical Society, April 3, 1883,
upon the question of the justifiability of operations for the removal of Cancer of the
Intestinal Tract.

One hundred cases of Antiseptic Ovariotomy. By John Homans, M.D., Boston,
1883.

Clinical Lecture on the Mechanical Treatment of Caries of the Lumbar Vertebra?.
By Dr. M. Josiah Roberts.

Elastic Tension therapeutically utilized in Adhesive and Medicated Plasters. By
Dr. M. Josiah Roberts, New York.

TO READERS AND CORRESPONDENTS.

Bilateral Secondary Descending Sclerosis and Atrophy mainly of Pons Varolii and
Medulla Oblongata. "By Wir. Julius Mickle, M.D., M.R.C.P., 1883.

The Higher Professional Life. Valedictory Address to the Graduating Class of Jef-
ferson Medical College. Philadelphia, April 2,1882. By J. M. Da "Costa, M.D.,
Professor of the Practice of Medicine.

The New Orleans Auxiliary Sanitary Association. Publication of Information con-
cerning Smallpox and Vaccination, for the benefit of the Public, written at the request
of the Association. By Prof. Stanford E. Chaille. M.D. New Orleans, June. 1883.

Hand-book of Medical Electricity. By A. M. Rosebrugh, M.D., Surgeon to the
Toronto Eye and Ear Dispensary, etc. Toronto, 1883.

Report on the Pharmacopoeias of All Nations. By Dr. James M. Feint, U. S.N.

Trichina? : their Microscopy. Development, Death, and the Diagnosis and Treatment
of Trichinosis. By W. C. W. Glazier, M.D., Assist. Surg. Marine Hosp. Service.
Detroit, Michigan, 1883.

Smallpox and Smallpox Hospital of New Orleans. New Orleans, 1883.

Case of Double Hydronephrosis with Dilatatiou of the Bladder and Ureters, due to
Disease of the Prostate Gland. By D. Webster Pbentiss, A.M.. M.D.

Report of the Committee on Ophthalmology, Ontario Medical Association, 1882.

The Bacteria. Bv T. J. Burrill, Ph. D., Professor of Botany in Illinois University.
Springfield. 1882.

The Opium Habit. Its Successful Treatment by the Arena Sativa. Bv E. H. M.
Sell, M.D., A.M., etc. 1883.

The Pathology and Morbid Anatomy of Tubercle. Bv N. Senn. M.D. Milwaukee,
1883.

Transactions of the American Medical Association. Vol. 23. Philadelphia, 1882.

Transactions of the Medical Association of Georgia. Augusta, 18S3.

Transactions of the State Medical Society of Wisconsin, 1882. Milwaukee, 1^S°>.

Proceedings of the Medical Society of the County of Kings. April to June, 1883.

Proceedings of the Naval Medical* Society. Vol. L Nos. 2, 3, 4. Washington, 18S3.

Proceedings of the American Pharmaceutical Association, 1882. Philadelphia, 1883.

Proceedings of the Connecticut Medical Society, 1882. Hartford, Conn.

First Annual Report of the Provincial Board of Health of Ontario, for the year 1882.

Tenth Annual Report of the Secretary of the State Board of Health of the State of
Michigan, for the fiscal year ending September 30, 1883. Lansing, Michigan, 1883.

Census of the City of Providence. January 1, 1883; taken under the direction of
Edwix M. Sxow, M.D., Superintendent.

Annual Report of the Retreat for the Insane at Hartford. Conn. April, 1883.

Report of the State Asylum for the Relief of Persons Deprived of their Reason, 1883.

Annual Report of the State Asylum for Insane Criminals, Auburn, N. Y. 1883.

Report of the State Lunatic Asylum at Utica, for 1882. Albany, 1883.

Fifth Annual Report of the Managers of the Adams Nervine Asylum, 1882. Boston.

Report of the Burlington County Hospital, for 1882.

Report of the State Board of Health of New Jersey, for 1882.

Fourth Annual Report, Board of Health, City of Memphis, 1882. By G. B. Thorn-
ton. M.D.. President.

Report of Investigation of the Central Kentucky Lunatic Asylum. Sept, 1882.

Report of Pennsylvania Training School for Feeble-Minded Children. 1882.

Report of the Trustees of the Massachusetts General Hospital, 1882. Boston.

Communicable Diseases in Michigan during the year ending September 30, 1882,
and Work of Boards of Health restricting the same. Lansing, 1883.

The usual American and foreign exchanges have been received ; their separate
acknowledgment is omitted for want of space.

Communications intended for publication, and books for review, should be sent
free of expense, directed to I. Minis Hats, M.D., Editor of the American Journal of the
Medical Sciences, care of Henry C. Lea's Son & Co., Philadelphia, Parcels directed as
above, and (carriage paid) under cover, to Messrs. Nimmo & Bain, Booksellers, No. 14
King William Street, Charing Cross, London, will reach us safely and without delay.

All remittances of money and letters on the busi?iess of the Journal should be ad-
dressed exclusively to the publishers, Henry C. Lea's Son & Co., No. 706 Sansom Street.

The advertisement sheet belongs to the business department the Journal, and all
communications for it must be made to the publishers.

CONTESTS

THE AMERICAN JOURNAL

THE MEDICAL SCIENCES.

NO. CLXXI. NEW SERIES.
JULY, 1883.

ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.

ART. PAGE

Cases of Lesions of Peripheral Nerve-Trunks, with commentaries. By
S. Weir Mitchell, M.D., Member of the National Academy of Sci-
ences, U. S. A. • . • . • • • • .17

II. On Contusions of the Brain and of the Spinal Cord. By John A.
Lidell, A.M., M.D., late Surgeon to the Bellevue Hospital, also late
Surgeon U. S. Volunteers, etc. . . . . . .31

III. A Demonstration of the Feeble Influence of Iodine over Malarial
Fevers, based upon an Analysis of 76 cases of Intermittent and Remittent
Fevers treated with the Agent. By I. E. Atkinson, M.D., Prof, of Patho-
logy in University of Maryland, and Hiram Woods, M.D., House Phy-
sician of Bay View Asylum, Baltimore . . . ... . .03

IV. The Field of Vision. By James L. Minor, M.D., Pathologist and
Assistant Surgeon to the New York Eye and Ear Infirmary . . .77

V. Some Points in relation to the Diagnostic Significance of Immobility of
one Vocal Band ; with especial reference to Anchylosis of the Crico-
Arytenoid Articulation and Aneurism of the Arch of the Aorta ; with Six
Illustrative Cases. By Solomon Solis Cohen, A.M., M.D., Demonstrator
of Pathology and Microscopy in the Philadelphia Polyclinic and College

for Graduates in Medicine ......... 84

VI. A Case of Primary Monomania (Primare Verrucktheit). By C. B.
Burr, M.D., Asst. Physician to the Eastern Michigan Asylum, Pontiac . 93

VII. Report of Eight Cases of Coxalgia in which Eleven Operations -of
Subcutaneous Osteotomy have been performed in the Children's Hospital,
Philadelphia. With Remarks. By H. R. Wharton, M.D., Surgeon to
the Children's Hospital, Demonstrator of Clinical Surgery in the Univer-
sity of Pennsylvania, and Assistant Surgeon to the University Hospital . 101

CONTENTS.

ART. PAGE

VIII. On Nasal Cough, and the Existence of a Sensitive Reflex Area in
the Nose. By John N. Mackenzie, M.D., of Baltimore, Md., Surgeon

to the Baltimore Eye, Ear, and Throat Charity Hospital . . .106

IX. Two Cases of "Paget's Disease of the Nipple." By Louis A. Duhr-
ing, M.D., Prof, of Skin Diseases in the University of Pennsylvania . 116

X. Experimental Keratitis : its bearing upon Strieker's theory of Inflamma-
tion. By James L. Minor, M.D., Ophthalmic Surgeon to the Randall's
Island Hospitals, Pathologist and Assistant Surgeon to the New York Eye
and Ear Infirmary . . . . . . . . . .120

XI. Enlargement of the Bronchial Glands as a Cause of Irritation of the
Pneumogastric Nerve. By Edward T. Bruen, M.D., Physician to the
Philadelphia Hospital, and Demonstrator of Clinical Medicine in the Uni-
versity of Pennsylvania . . . . . . . . . .125

XII. A Study of some recent Experiments on Serpent Venom. By Robert
Fletcher, M.R.C.S.E., Washington, D. C 131

XIII. Extensive Interlobular Emphysema and Abscess of the Lung, after
Whooping-Cough, in a Child of two months. — Unique Case. By William

P. Northrup, M.D., Pathologist to the New York Foundling Asylum . 147

XIV. An Anomaly of the Human Heart. By H. Horace Grant, A.M..
M.D., Lecturer on Operative and Minor Surgery, and late Demonstrator

of Anatomy, Kentucky School of Medicine, Louisville . . . .149

XV. Statistics of 272 Lithotomy Operations. By Nishan Altounian, M.D.,
of Turkey in Asia. Translated from the Armenian by his son Melkan Z.
Altounian, M.D. (Jefferson Medical College) 151

XVI. The Radical Cure of Varicocele. By H. Lawrence Jenckes, M.D.,

of Glen Haven, AVisconsin . . . . . . . . .153

REVIEWS.

XVII. The Medical and Surgical History of the War of the Rebellion.
Part III. Vol. II. Surgical History. Prepared under the direction of
Joseph K. Barnes, Surgeon-General United States Army. By George A.
Otis, Surgeon U. S. A., and D. L. Huntington, Surgeon U. S. A. 4to.

pp. xii., 986, xxix. Government Printing Office, Washington, 1883 . 155

XVIII. The Pathology and Treatment of Diseases of the Ovaries (being
the Hastings Essay for 1873). By Lawson Tait, F.R.C.S., Edinburgh
and England, Surgeon to the Birmingham Hospital for Women, Honorary
Fellow of the American Gynaecological Society, etc. Fourth edition, re-
written and greatly enlarged. New Y^ork : William Wood & Co., 1883 172

XIX. Annual Report of the Medical Officer of the Local Government
Board for the year 1881. London, 1882 190

XX. Transactions of the Obstetrical Society of London. Vol. XXIV., for
the year 1882. 8vo. pp. 339. London : Longmans, Green & Co., 1883 193

XXI. A Treatise on Fractures. By Lewis A. Stimson, B.A., M.D., Pro-
fessor of Surgical Pathology in the Medical Faculty of the University of
the City of New York, Attending Surgeon to the Bellevue and Presbyte-
rian Hospitals, New York, etc. 8vo. pp. 598. Philadelphia: Henry

C. Lea's Son & Co., 1883 198

CONTENTS.

ART. PAGE

XXII. Lectures on Orthopedic Surgery and Diseases of the Joints. By-
Lewis A. Sayre, M.D., Professor of Orthopedic and Clinical Surgery in
Bellevue Hospital Medical College, etc. etc. Second edition, revised,
and greatly enlarged, with 324 illustrations. 8vo. pp. xx. 569. New
York: D. Appleton & Co., 1883 203

XXIII. A Manual of Practical Hygiene. By Edmund A. Parkes, M.D.,
F.R.S., late Professor of Military Hygiene in the Array Medical School,
Member of the General Council of Medical Education, Fellow of the
Senate of the University of London, Emeritus Professor of Clinical Medi-
cine in University College, London. Edited by F. S. B. Francois De
Chaumont, M.D., F.R.S., Fellow of the Royal College of Surgeons of
Edinburgh, Fellow and Chairman of Council of the Sanitary Institute of
Great Britain, Professor of Military Hygiene in the Army Medical School.
Sixth edition. 8vo. pp. xix. 731. Philadelphia, Pa. : P. Blakiston, Son

& Co., 1883 . . . . . 206

XXIY. Health Reports.

1. First Annual Report of the Provincial Board of Health of Ontario,

being for the year 1882. Toronto, 1883, pp. 223.

2. Fifth Annual Report of the Connecticut State Board of Health for

1882, with Registration Report for 1881. Hartford, 1883, pp. 445.

3. Sixth Annual Report of the State Board of Health of New Jersey,

1882. Woodbury, X. J., pp. 361.

4. Tenth Annual Report of the Secretary of the State Board of Health

of Michigan, for 1882. Lansing, 1883, pp. 630 . . . 210

XXV. The Dispensatory of the United States of America. By Dr. Geo.

B. Wood and Dr. Franklin Bache. Fifteenth Edition. Rearranged,
thoroughly Revised, and largely Rewritten. With Illustrations. By H.

C. Wood, M.D., Member of the National Academy of Science, Professor
of Materia Medica and Therapeutics, and of Diseases of the Nervous
System, in the University of Pennsylvania ; Joseph P. Remington,
Ph.G., Professor of the Theory and Practice of Pharmacy in the Phila-
delphia College of Pharmacy, First Vice-Chairman of the Committee of
Revision and Publication of the Pharmacopoeia of the United States of
America; and Samuel P. Sadtler, Ph.D., F.C.S., Professor of Chemistry
in the Philadelphia College of Pharmacy, and of General and Organic
Chemistry in the University of Pennsylvania. Octavo, pp. 1928. Phila-
delphia: J. B. Lippincott & Co., 1883 215

XXVI. Medical Essays ; 1842-1882. By Oliver Wendell Holmes. 12mo.

pp. x. 445. Houghton, Mifflin & Co., Boston. New York, 1883 . .219

XXVII. A Text-book of the Diseases of the Ear and Adjacent Organs.
By Dr. Adam Politzer, Imperial-Royal Professor of Aural Therapeutics
in the University of Vienna, Chief of the Imperial-Royal University Clinic
for Diseases of the Ear in the General Hospital, etc. Translated and
edited by James Patterson Cassells, M.D., M.R.C.S. Eng., Aural Sur-
geon to and Lecturer on Aural Surgery at the Glasgow Hospital and Dis-
pensary for Diseases of the Ear. 8vo. pp. 800. Philadelphia: Henry C.
Lea's Son & Co., 1883 220

CONTENTS.

ART. PAGE

XXVIII. A Practical Treatise on Diseases of the Skin, for the Use of
Students and Practitioners. By James Kevins Hyde, A.M.. M.D., Pro-
fessor of Skin and Venereal Diseases, Rush Medical College, Chicago ;
Dermatologist to the Michael Reese Hospital, Chicago, etc. 8vo. pp.
572. Philadelphia: Henry C. Lea's Son & Co., 1883 .... 222

XXIX. La Trichine et la Trichinose. Par Joannes Chatin. Maitre de Con-
ference a la Faculte des Sciences de Paris. Professeur Agrege a l'Ecole
Superieure de Pharmacie. Avec 11 planches. Paris : J. B. Bailliere et
fils, 1883 • • -227

XXX. A System of Human Anatomy, including its Medical and Surgical
Relations. By Harrison Allen, M.D., Prof, of Physiology in the Uni-
versity of Pennsylvania, etc. etc. Philadelphia: Henry C. Lea's Son

& Co., 1882-3 . . . 229

XXXI. Quain's Elements of Anatomy. Edited by Allen Thomson, M.D.,
D.C.L., LL.D., F.R.S., Edward Schafer, F.R.S., and George Dancer
Thane. Ninth Edition, 2 vols. 8vo., pp. xiii., 748, and ix., 947. New
York: William Wood & Co., 1882 232

XXXII. Transfusion: Its History, Indications, and Modes of Application.
By Chas. Egerton Jennings, L.R.C.P. Lond., etc. With Engravings
illustrating the Author's Siphon for Intravenous Injection and Immediate
Transfusion, and a Bibliographical Index. 8vo. pp. viii. 69. London :
Balliere, Tindall, & Cox, 1883 233

XXXIII. A Manual of Chemical Analysis as applied to the Examination
of Medicinal Chemicals. A Guide for the Determination of their Identity
and Quality, and for the Detection of Impurities and Adulterations. For
the Use of Pharmacists, Physicians, Druggists. Manufacturing Chemists,
and Pharmaceutical and Medical Students. Third edition, thoroughly
revised and greatly enlarged. By Fredei'ick Hoffmann, A.M., Ph.D.,
Public Analyst to the State of New York, and Frederick B. Power,
Ph.D., Professor of Analytical Chemistry in the Philadelphia College of
Pharmacy. 8vo. pp. 624. Philadelphia: Henry C. Lea's Son & Co.,
1883 235

XXXIV. Das Naphthalin in cler Heilkunde und in der Landwirthschaft.
Naphthalin in Medicine and in Agriculture. By Dr. Ernst Fischer, Pri-
vat docent of Surgery in Strassburg. 8vo. pp. 98. Strassburg: Karl J.
Trubner, 1883 . 237

XXXAT. Student's Guide to Diseases of the Eye. By Ed. Nettleship,
F.R.C.S., Ophthalmic Surgeon to St. Thomas's Hospital and to the
Hospital for Sick Children. Second American from the second revised
and enlarged English edition. With a chapter on Examination for
Colour Perception, by Wm. Thomson, M.D., Prof, of Ophthalmology in
the Jefferson Medical College. 8vo. pp. 416. Philadelphia: H. C.
Lea's Son & Co., 1883 239

XXXVI. Sore Throat : its Nature, Varieties, and Treatment ; including
the Connections between Affections of the Throat and other Diseases.
By Prosser James, M.D., Physician to the Hospital for Diseases of the
Throat and Chest. Fourth edition, enlarged, with coloured plates and
wood engravings. 12mo. pp. 318. Philadelphia: P. Blakiston, Son &
Co., 1882 . 240

CONTENTS.

QUARTEELY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

Anatomy and Physiology.

page

Partial Regeneration and New
Formation of the Liver. By
Tissoni . . . . 241

A New Crystalline and Coloured
Body in the Urine. By Ploz . 242

PAGE

Urine Ferments and Fermentation.
By Bechamp . . . .242

Hemorrhage by Vaso-motor Irrita-
tion. By M. Brown- S6quard . 243

Materia Medica and Therapeutics.

Physiological Effects of Cinchoni- j Therapeutic Use of Nitro-fflvcer-
dine. By MM. G. S6e and | ine. By Dr. Henri Huchard . 246
Bochefontaine .... 243 Subcutaneous Injections of Stimu-

Physiological Action of Veratrine. lants. By Dr. W, Zuelzer . 246

By MM. Pecholier and Redier 243 Bismuth Treatment of Wounds.

Eucalyptus Steam in Infectious By Kocher .... 248

Diseases. By Mr. J. Murray Bismuth Treatment, of Wounds.

Gibbes ..... 244 By Drs. Riedel, Kocher, von

Langenbeck, and Israel . . 250

Medicine.

Erythematous Eruption in Enteric j Catarrhal Ulceration. By Prof.
Fever. By Dr. Whipham . 250 j Virchow 260

The Pythogenic Micrococcus of Antiseptic Inhalations in Pulmo-
Erysipelas. By Fehleisen . 253 j nary Disease. By Dr. Arthur

The Differential Diagnosis of Urae- Hill Hassall . . . .260

mic Coma from the Coma of j Iodoform in Chronic Pulmonary
Cerebral Hemorrhage. By Dr. Affections. By Prof. Semmola 261

T. A. McBride . . . 254 Nitric, Nitrous, and Nitro-com-

Hemorrhage of the Nerve Centres j pounds in Angina Pectoris. By
in the Course of Purpura Hasmor- Mr. Matthew Hay . . . 262

rhagica. By Dr. Duplaix . 255 ! Treatment of Angina Pectoris. By

A Case of Tachetic Symmetrical Prof. Germain See . . . 262

Gangrene By Dr. Southey . 255 j Purulent Pericarditis, Paracente-

A Case of Tabetic Arthropathy in sis, and Free Incision ; Recovery,
which the Tarsal Bones of both By Dr. Samuel West . * . 263
Feet were involved. By Mr. j Perisplenic Abscesses. By M. C.
•Herbert Page . . . . 258 j Zuber 266

Primary Stenosis of the (Esopha- Habitual Constipation. By Dr. J.

gus. By M. Debove . . 259 j Mortimer Granville . . . 266

CONTENTS.

Percussion of the Colon in the Di-
agnosis of Diarrhoea. By Dr.
Goedicke . . . . .267

Alterations Produced by the Dis-
toma Haematobium in the Uri-

PAGE

nary Passages and Large Intes-
tines. By Dr. Zancaral . . 268
Leucoderma. By Dr. Thomas F.
Wood 269

Surgery.

Transplantation of Skin-flaps from
Distant Parts without Pedicle.
By Dr. J. R. Wolfe . .270

Removal of Extensive Cavernous
Angioma of the Scalp by the
Elastic Ligature. By Dr. George
R. Fowler . . . .271

Tracheotomy in Croup and Diph-
theria. By Dr. H. Lindner . 272

Excision of the Abdominal Wall.
By Prof. Sklifosovsky . .274

Healing of Wounds of the Spleen.
By A. Dannenburg . . .275

A Case of Nephrectomy for Rup-
ture of the Kidney where Lateral
Cystotomy was also subsequently
performed for the Relief of Cys-
titis caused by Retained Blood-
Clots. By Dr. Henry G. Row-
don ...... 275

Case of Excision of an Enlarged
Cancerous Kidney. By Sir
Spencer Wells . . . .276

Nephrectomy. By Dr. Dickinson 276

Resection of the Intestine. By
Prof. Edward von Wahl . .278

Abdominal Tumour consisting of
Hair. By Prof. Schonborn . 279

Fatal Hemorrhage from Naevus of
the Rectum. By Mr. Arthur E.
J. Baker 279

Controlling Hemorrhage in Ampu-
tation at the Hip-joint. By Mr.
Jordan Lloyd .... 280

Ligation of large Arteries by the
Application of two Ligatures and
Division of the Vessel between
them. By Mr. W. J. Walsham 281

Deligation of the Common Carotid.
By Wei] amino w . . .282

Nerve Stretching. By Dr. Cec-
cherelli 283

Subperiosteal Resections . . 284

Resection of the Wrist. By Dr.
G. Nepveu . 286

Resection of the Knee. By Oilier 286

Ophthalmology and Otology.
Chloroma. By Billroth . . .287

Midwifery and Gynaecology.

Treatment of Placenta Praevia. By
Dr. Hofmeier .... 288

Treatment of Post-partum Hemor-
rhage in Cases of Placenta Prse-
via. By Klotz . . .289

Metria. By Dr. Atthill . . 290

Vaseline in Obstetrics. By Dr.
Koch _ . . . .291

Vaccination during Pregnancy ; its
Effect on the Foetus. By Dr.
Carl Behm . . . .291

A Case in which Cysts in connec-
tion with both Kidneys were

opened and drained, and a Tu-
mour of the Right Ovary re-
moved, the patient remaining in
good health. By Mr. Knowsley
Thornton . . . .292

The Propriety of Operating in
Cases of Solid Ovarian Tumours.
By Mr. Knowsley Thornton . 293

Fibroma of the Round Ligament.
By Prof. Ludwig Klein w'achter 295

The Sharp Spoon in Gynaecology.
By Dr. v. Weckbecker-Sterne-
feld 295

Medical Jurisprudence and Toxicology.
Intra- peritoneal Injections in Cases of Poisoning. By Dr. Wm. Murrell . 296

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR JULY 1 8 83.

Article I.

Cases of Lesions of Peripheral Nerve-Trunks, with commentaries.
By S. Weir Mitchell, M.D., Member of the National Academy of
Sciences, U. S. A.

Case I. Peculiar Nutritive Changes of Palm and Back of Hand as-
cribed to Milking ; Herpes; Neuralgia ; Elongation of Median Nerve ; Sec-
tion of Radial Nerve. — L. C, set. 40, first came to the Infirmary for Ner-
vous Diseases in Nov. 1880, with the following brief history : Some ten
years ago she noticed a numbness in the palm of the right hand, apparent,
however, only when milking cows, though six months later she also observed
it during ironing. Succeeding this " numbness," pain made itself manifest,
affecting the palm and all the fingers of the hand, but not extending up
the arm. This condition grew gradually worse, until two years ago she
was unable to make use of the hand on account of the suffering. The
trouble was most apparent in the morning when first awakening, and was
increased both in extent and intensity by cold, while warmth or pressure
in a measure relieved it. On examination the pain was found to be located
in the palm between the second and third metacarpal bones, and to extend
through to the dorsal aspect of the hand. No pain was felt elsewhere,
nor did pressure along any of the nerve tracts either of the hand or arm
disclose any other painful spot, although a callosity about the size of a pea
was noticed upon the anterior surface of the wrist. Sensation as to touch
appeared to be normal, and the muscles were firm and well developed,
though the dynamometer indicated a loss of strength in the affected hand.
There was, however, neither muscular atrophy, contractions, joint disease,
glossy skin, nor even the changes in nail-growth which usually accompany
impairment of nutrition.

Some three months ago a herpetic eruption made its appearance in a
small area on the back of the affected hand. She has also presented for
some years on the face and breast a bronzed appearance similar to the
bronzing of Addison's disease. Beyond the points mentioned she was
in excellent general health. At the time of her first visit, sulphate of
No. CLXXI.—July 1883. 2

Mitchell, Lesions of Peripheral Nerve-Trunks. [July

strychnia was prescribed, one-fortieth gr. t. d., and she was directed to in-
crease the dose to the one-twentieth or., while the lactate of iron was
also ordered in doses of three grs. t. d.

In April, 1881, she returned, reporting considerable improvement. The
eruption, however, had become a distinct sore, eczematous in character,
and some little time previous it had begun to discharge a thin, grayish-
yellow pus, although the diseased region was not painful to the touch ;
whenever it healed, and the discharge ceased, the pain became much
worse. She was given Fowler's solution at the time of her second visit,
beginning with five drops t. d., and the amount gradually increased till
toxic effects were produced. Galvanism was also ordered to be applied
to the hand and arm with special reference to the median and musculo-
spiral nerves, one electrode being placed over the sore spot in the hand.
During May and June, 1881, she received twenty-eight applications of
the continuous galvanic current, which acted very favourably. The pain
in the hand lessened so considerably as to cause but little trouble, while
the sore on the back of the hand gradually healed. There was no longer
any discharge or desquamation, and all that was left was a spot of red-
dened and somewhat hypertrophied skin. In August the trouble again
became worse, and a small abscess of the size of a pea formed on the back
of the hand, between the first and second metacarpal bones. Following
this, a second small abscess appeared on the ulnar aspect of the forearm,
while a third formed in the palm. In addition to these, other abscesses
have developed from time to time, one near the middle of the radial side
of the forearm, and more recently one rather high up on the posterior sur-
face of the forearm, while at one time there were four present, all on the
dorsal aspect of the hand, two over the metacarpal bone of the thumb,
one near the base of the second and third metacarpals, and the last just in
front of the styloid process of the ulna. At no time has she had any ab-
scesses above the elbow.

The treatment by the continuous galvanic current was persisted in faith-
fully for a long period, but, as it did not afford any permanent relief, it
was finally decided to resort to more positive measures. I advised that
one or both of the nerves supplying the affected part, the median and
radial, be stretched, and she entered the hospital the 9th of February, 1882.
At a consultation with the surgeons, Drs. Hunt and Morton, it was
thought well to try specific treatment before resorting to operative meas-
ures, and she was, therefore, put on large doses of the iodide of potassium
and given mercurials, with, however, no beneficial results. Hence it was
finally resolved to stretch the median nerve ; but to await the result of
this measure before disturbing the radial.

On the 9th of March the median was cut down upon, caught up on a
tenaculum and thoroughly stretched, not only by traction, but also by
allowing it to support for a minute the full weight of the arm. During
the stretching, the pulse was peculiarly affected, becoming slow, hard, and
full, the retardation lasting for some two hours after the operation. She
reacted well from the ether, but appeared to suffer slightly from shock, the
extremities becoming quite cold. The edges of the incision were care-
fully united by sutures and the hand supported on a straight anterior
splint. Toward evening she. complained of a burning pain along the
course of the nerve extending up to the brachial plexus. But with this
exception and that of a slight soreness through the wrist, no trouble
ensued, and by the 15th day the wound was entirely healed.

1883.] Mitchell, Lesions of Peripheral Nerve-Trunks.

As a result of the operation, the following facts were noticed : Two
hours after the operation, the temperature of the right hand, as indicated
by a surface thermometer, was two degrees higher than that of the other.
Four days later a careful examination by Dr. Morris Lewis disclosed an
increased area of dysesthesia, the loss of sensation apparently including a
part of the radial distribution. There was but little of the former pain,
but some sense of numbness, while a forming abscess was rapidly crust-
ing over, and a small blister, the sure precursor to an ulcer, which had
begun to appear on the back of the hand previous to the operation, had
entirely disappeared. Within the third week the pain recurred with all
the former severity, and for the next month she had several returns of
neuralgia as severe as any former attack, although of short duration. A
"sore spot" also appeared on the web, between the thumb and forefinger
together with a dull aching of the wrist, and tenderness along the line of
the cicatrix.

On the 2d of May she was ordered massage of the affected arm from
the shoulder downwards, especial care being directed to the kneading of
the muscles of the hand. A sedative lotion was also applied, as it appeared
to have some favourable influence upon the pain, which was causing her as
much suffering as at any previous period. On the 5th of May static elec-
tricity was employed daily, an electrode being approximated to either
side of the hand and sparks passed through it. This treatment appeared
to relieve the pain temporarily, the static current acting more favourably
than the galvanic current, in that it produced no burning sensation what-
ever, while it possessed as marked an influence over the pain.

But none of these measures were of any permanent value ; indeed on
May 16, a small bleb had made its appearance on the back of the hand
and soon ruptured, leaving a superficial ulcer, so that it was evident that
the stretching of the median nerve had not resulted in any material re-
lief. A month of grace was yet allowed, but as the matter became
gradually worse, on the 14th of June it was thought well to interfere
witli the radial distribution. Inasmuch as simple stretching of the me-
dian nerve had proved ineffectual, it was resolved to employ the more
radical treatment of nerve section. The operation was performed under
ether by Dr. Hunt, assisted by Dr. Morton, and one and three-quarter
inches of the radial nerve were removed just above the wrist. No serious
consequences followed, the patient reacting well, though the same slowing
of the pulse was remarked as in the previous operation. A straight splint
was applied to the forearm with a dressing of lint and cosmoline, while a
teaspoonful of the officinal solution of morphia was exhibited internally.
The healing of the wound was rapid, and attended with little pain, which
was referred wholly to the neck and shoulder, the hand being entirely
free from the former aching and burning sensations. On the 30th of
June, she was discharged greatly relieved.

At present, November 16, her condition is as follows: She is very
much improved in her general appearance, and since the last operation she
has had no eruption on the back of the hand, nor any severe pain through
the palm. There is, however, a nearly constant aching in the fleshy
portion of the hand increased by use, which is also followed by very
severe aching sensations in the shoulder and neck similar to those that
came on directly after the operations. The first cicatrix causes her no
inconvenience whatever, while the second, sensitive even to the friction
of the clothing, is still very tender.

Mitchell, Lesions of Peripheral Nerve-Trunks.

[July

Remarks It is not the number of cases which adds to our knowledge

so much as the care with which each is studied, and in no branch more
than in nerve injuries is this illustrated. Unhappily, in the past these
cases have fallen almost wholly into the hands of the surgeons, who are
largely accountable for the lost opportunities they represent.

Fiar. 1.

Dorsum.

The present case, of which I have just given a detailed history, will
bear some comment. The patient ascribes its onset to the act of milking
cows. It seems possible that this might give rise — nay is sometimes known
to give rise to loss of power — similar in character to the pareses of the
writer — but it appears difficult to comprehend how it could be the parent

1883. J Mitchell, Lesions of Peripheral Nerve-Trunks.

of such a condition as this person presented when first I saw her. Never-
theless she persists in stating that at first the numbness with which her
trouble began was only felt while milking. This may well have been,
and yet the act of milking not be responsible for the origin of the disease.
The pain and discomfort were the chief reasons for resort to operation.

Fie-. 2.

Palm.

and there was in my mind much doubt as to what nerve I should attack.
For although the herpes and ulcers and much of the pain were distinctly
in the radial distribution, the original seat of pain was in the palm at the
point of divergence of the median branches. I finally decided to stretch
the median. On the 11th of February, two days after an attack of pain,

Mitchell, Lesions of Peripheral Nerve-Trunks. ['July

Dr. Morris Lewis, assistant physician to the Infirmary, made a careful
study of the areas of disturbed sensation, and mapped them out in colours
on a cast of a hand, as represented in Diagrams Nos. 1 and 2. A care-
ful examination of these figures, and of those made at later dates, will
show some of the obscurities which still surround this most difficult
question of nerve distribution, and of the effects of stretching or section.

Fig. 3.

Palm.

The region of dysesthesia, that is, of defective sensation of touch, is
included within the continuous lines. It is remarkably irregular, and
covers most of the median, and some of the ulnar and radial territory,
but does not include all of any one of these nerve distributions. The

1883.] Mitchell, Lesions pf Peripheral Nerve-Trunks. 23

regions of ulceration and herpetic eruption are stippled, and the two
points of occasional causalgia are marked as B B, and the points where
abscesses occurred, by the letter A.

On the 9th of March the median nerve was stretched. I then observed
for the first time what is, perhaps, a common phenomenon, the sudden slow-
Fig. 4.

ing of the pulse at the moment of stretching the nerve. The pulse fell
from 98 to 80, and continued to preserve this rate for two hours.

Stretching raised the temperature two degrees in the median territory
precisely as happens after section. On March 28th, nineteen days after
the operation, Dr. Morris Lewis made for me the diagrams Nos. 3 and 4.

Mitchell, Lesions of Peripheral Nerve-Trunks. [July

The area of the original dysesthesia had widened so as to include regions
within the ulnar and radial distribution as well as the median. The space
thus lessened in sensibility is remarkable ; nor is it possible to explain its
extent by any theory of direct effects, or by any unusual distribution of
the median. We must, I think, conclude that the centres were in some

Fig. 5.

Dorsum.

way widely influenced by the operation. Certainly, the observation is
both novel and interesting. The dysesthesia as to touch so caused was
much alike throughout, and the pain sense was merely deadened, not
lost, and varied in degree within the affected space.

The first beneficial influence of the operation was to lessen the causalgia

1883.] Mitchell, Lesions of Peripheral Nerve-Trunks.

and relieve the trophoneurosis. The return of these symptoms after some
months, and the continuous increase of pain in the forearm1 and arm, in-
duced me finally to resort to further measures. Accordingly Dr. Hunt,
on the 11th of June, 1882, divided the radial nerve just above the wrist.
The slowing of the heart was again observed, and the usual rise of

Fig. 6.

/ ]

temperature. The operation again, and still further, extended the dys-
esthesia. The patch of good sensation in the dorsal ulnar region remained
nearly as before, and some slight changes were seen in the dorsal and pal-
mar aspect of the fourth and fifth digits. In the wrist and arm there was
a large extension of the dysaesthetic areas, whilst on the back of the hand

Mitchell, Lesions of Peripheral Nerve-Trunks.

[July

there was found an irregular region shaded black in Diagram 5, within
which all sense of pain as well as of touch was lost. This area is of un-
usual form, since after radial nerve section these losses are not found to be
as extensive as in the present case. As a rule, section of the radial leaves
the dorsal aspect of several, and sometimes of all of the fingers, more or
less insensible to touch, but in the present case there is no increase of the
previous defect, nor any added dysesthesia of the fourth and fifth digits.
For what it destroyed and for what it left unaltered this section is remark-
able. See Diagrams 5 and 6. It may be noticed in Diagrams 3 and 4, that
stretching the median left a little spot of normal feeling at the base of
the palmar face of the thumb. Section of the radial left a similar spot
rather nearer to the dorsum, at the base of the thumb, but around it was
found in addition a narrow band (one line in breadth) of well-marked
burning pain and hyperesthesia. Diagrams 5 and 6 (D).

Amongst the various points of interest in this case, none exceeds in
value the abrupt extension of the areas of lessened sensation which was
seen after the operations on the median and radial nerves. I have said
that this was not to be accounted for upon any knowledge we now have of
the peripheral distribution of nerves — since in one case the dysesthesia
spread far beyond the region tributary to the nerve stretched or cut ; and,
in the other, in some directions did not cover the whole regions usually
affected after radial nerve sections. As I have been very watchful of my
cases, I can be sure that this is not a common incident of sections of nerves.
But it is not altogether new to my experience. Generally speaking, the
symptom is to be considered as one of the many forms of shock. A sudden
injury to a nerve already morbidly altered gives rise to an inhibition of
function in certain closely related centres. The disturbance might be
in the direction of motor or of sensory inhibition, and both forms are
among the rarer phenomena of nerve wounds from rifle-balls. The fact
itself is less surprising than its permanence, nor is it easy to comprehend
the precise nature of an influence which may act on such varied func-
tions, and act so persistently.

The curative results of the operation remain after ten months all that
I could wish them to be.

Case II. Facial Neuralgia, originating in the Left Supra-Orbital
Nerve, and finally affecting other branches, relieved by Section of the
Infra-Orbital Nerve — Mrs. M., ast. 68, had for some years suffered with
pain which arose first in the left supra-orbital nerve, and now for some
months affected with equal and extreme severity the infra-orbital nerve,
and at times the infra-maxillary.

As every imaginable drug had been used, and galvanism failed to re-
lieve, I decided to divide both the supra- and infra-orbital nerves at one
sitting.

The case is brought forward to illustrate a point of practical value, and
of extreme importance. If I had had to choose which single nerve I

1883.] Mitchell, Lesions .of Peripheral Nerve-Trunks.

should sever, I should certainly have selected the supra-orbital, in which
the pain began. It chanced that I was indisposed at the time set for the
operation, and therefore sent word to my colleagues, Dr. Hunt, who ope-
rated, and Dr. Morton, who assisted him, to go on without me. In this
consultation they concluded as a measure of prudence to divide but one
nerve, and not being aware of the reasons which would have then led me
to choose the supra-orbital, they divided the infra-orbital nerve.

The results were, however, to annihilate pain in all branches of the
fifth nerve, and to leave on my mind a most valuable lesson, since nine
months later the same satisfactory condition of things still exists.

The mode of reaching this nerve is not a matter of indifference.

In this case the antrum was broken into, and, if I correctly remember,
my friend Prof. Brinton, who has operated for me several times on the
infra-orbital, prefers this operation. On the whole, however, it seems to
me desirable not to break into the antrum. Indeed, I should like in a
future case, merely to cut the nerve in front, and again far back in the
orbit, and then to leave a small plug of bone or ivory in the little canal,
or to close the canal with dental cement. I do not observe that in this
case the scar is tender, nor in fact is it apt to be — whilst it is frequently
the case when incisions are made on the forearm and a large nerve is cut
that the cicatrix remains tender.

Case III. Neuralgia of Left Inferior Mamillary Nerve ; Extension of
Pain to other Branches ; Section of Nerve; Return of Pain; Second
Section and Obliteration of Canal with Dental Cement, January 28,
1883. — Miss — , of New Jersey, set. 43, underwent in April, 1881, by my
advice, a resection of the inferior dental nerve on the left side, the opera-
tion being performed by Dr. Morton. The case and the immediate results
were reported in The Medical News for March 11, 1882.

After a long period of ease, some time in March or April, 1882, the
pain returned in the jaw at the old seat, and in June, 1882, had be-
come as bad as before. The pain had all the usual peculiarities of these
neuralgias, and was not limited to the lower nerve, but was felt in both
the temporal and orbital branches. At my desire, her home adviser, Dr.
Ed. North, of Hammonton, gave her very large doses of aconite, which
certainly abolished the pain; but in December, 1882, it returned anew,
and in January, 1883, she was readmitted in a pitiable state of suffering.
On close study it was found that sensation had been restored in the area
figured in my last report of her case as having lost it. In some places
the touch sense was still imperfect, but it was nowhere destroyed, and
throughout a needle prick could be felt. Clearly the nerve had been re-
made, and I was again face to face with this difficult question. After
exhausting all means at pur disposal, it was agreed, in consultation, to
seek for the nerve in the canal at the point where formerly it had been
severed, and to divide it anew.

At the same time I felt that the operation might fail, like the last one,
to give permanent relief, but that at least I should be more secure if I
could in some way provide against reunion of the nerve ends. I had
thought of plugging the canal with bone or ivory, or of thrusting peri-
osteum into it, but finally decided to fill it with dental cement.

Mitchell, Lesions of Peripheral Nerve-Trunks.

[July

On January 28th, Dr. Morton operated, the patient having been ether-
ized. On exposing the bone, a small trephine was applied about an inch
and a quarter in advance of the angle of the jaw, but the canal thus un-
covered was ill-defined, and amidst the crushing caused by the trephine,
the bleeding, and the obscure cancellous structure, we could find or see
no re-made nerve. When the tissues were' pushed back a little the old
trephine mark was disclosed. It had filled up with bone except for an
opening about a line wide, from which projected a button-like promi-
nence, which proved to be a stump of nerve tissue. Unhappily the knife
had swept over it, and whether or not it furnished filaments running for-
ward over the bone cannot now be known.

On trephining, so as to include it, we failed again to trace filaments
running along the irregular canal, which certainly existed. The operation
enabled us to pull out the nerve trunk some distance, and after stretching
to sever it. A more careful search was then made for the filaments pre-
sumed to have reconnected the central end with the sensitive skin spaces
on the chin. Finding none, the canal was cleaned out, and the two ends
of the canal thoroughly filled with warm dental cement, which admits of
being easily moulded when hot, and then hardens. What is to be the
result of this very novel procedure we have yet to see. Sensation was
again destroyed in the region fed by the inferior maxillary nerve, showing
that the nerve had been remade and again severed during the operation.
At this date — May 10, 1883 — there has been a recent return of neuralgic
pain, but so far no inflammatory disturbance from the presence of the
cement, as to the use of which both Dr. Morton and I have had such
anxiety, as naturally attends the use of perfectly new methods. The
same mode of obliterating the canal has been more recently resorted to by
Dr. Morton in another case of resection of the infra-maxillary nerve.

Case IV. Affection of Nerves of Left Arm; Remarkable Lowering of
Temperature — September 4, 1882. S. M., male, ret. 51, distributing
agent in mail car. Has had good health, with the exception of some dys-
pepsia ; has never had syphilis ; has used little or no tobacco, and is tem-
perate in all ways.

During the war his right elbow was injured by a ball, the joint subse-
quently undergoing ankylosis. Owing to this he has been compelled to
perform an unusual proportion of work with the left hand, especially in
the distribution of mail matter.

About one year ago he noticed a certain loss of power in the fourth and
fifth fingers of the left hand without numbness or pain. Two or three
weeks subsequently the weakness extended to the other fingers of the left
hand, and was then accompanied by some pain in the forearm. At this
time (September 5, 1881) he was compelled to give up work, but this
weakness has not grown worse since. For the last six months, on the
approach of storms, he has had pain extending from the shoulder to the
finger-tips.

The pain-sense is somewhat blunted in the hand and the lower half of
the forearm. The touch-sense is also defective, and in the finger-tips the
limit of confusion of the compass points is six lines.

There is no atrophy in the arm. All the hand muscles are wasted,
though not excessively. There is occasional tremor in the index finger,
and also in the second finger. Dynamometer, right, 100 ; left, 60. No
loss of mobility in the arm. He can extend and flex the hand, and extend
and flex the fingers perfectly, except the third and fourth fingers, extension
of which is imperfect. He can oppose the thumb to the forefinger, but

1883.] Mitchell, Lesions of Peripheral Nerve-Trunks. 29

not to the other fingers. Is unable to button his clothes, or to pick up
any object with the fingers.

The appearance of the unsound hand is singular. It is mottled dark
red and pale red, or is throughout of a deep dusky red, especially as to
the nails. The skin is smooth rather than glossy, sweats with great ease,
and is usually cold to the touch. In fact a subsequent careful examina-
tion of the temperature of the two hands showed a remarkable difference.
On January 15th, for instance, the sound hand stood at 98.2° Fahr. ; the
unsound hand 93.4°. After massage for thirty minutes, the temperature
became : sound hand, 98.6° ; unsound hand, 98.5°.

The next day, January 16th, the hands were, at 10.30 A.M. : sound,
98.7°; unsound, 95°. After reaction, consequent on being out in the
cold, they stood : sound hand, 88.8° ; unsound hand, 91.2°.

Observations taken subsequently at different times showed the tempera-
ture of the unsound hand to fluctuate between 98.8° and 93.2°. On one
occasion, when the sound hand showed 97.3°, the unsound one registered
83.2°. During these observations the temperature in the left axilla re-
mained 98.6°.

The reflex actions of the hand are markedly increased. A tap on any
portion of the arm below the elbow, whether on muscle or on bone, gives
a flexor reflex, which is much more energetic when the tendons are struck.
Tapping the extensor tendons in the wrist or hand, gives also a marked
reflex action. Direct mechanical irritation, as of a. tap with a rubber
mallet, will cause fibrillary, or entire contraction in any muscles of the
forearm or hand over a space corresponding to the area of the percussing
body.

Electrical condition : F. C, Eeaction slightly lessened, but present in
all the muscles and nerves.

Galvanic C. Quantitative lessening only, the normal formula of polarity,
Ka.S.Z An. S. z remaining unchanged.

Under the steady use of tonics and galvanic electricity, with daily
massage, the hand gradually improved in power, and the pain entirely
disappeared.

The remarkable feature of the case was the fall of temperature, a symp-
tom exceptionally rare in examples of any form of neuritis, whether of
internal or of traumatic origin, and one which I find it quite impossible
to explain. Certainly, in the more frequent cases of inflammation of the
nerves of the hand itself with causalgia — absent in this case — there is a
rise and not a fall of temperature. In the present instance, a rare one,
the nerve tracts on the hand were not sensitive to pressure, the joint and
nail lesions were but slight, and the shining skin of causalgia was not
well marked. On the other hand, the nerve tracts in the neck, axilla,
and arm were tender.

Nothing which we know7 as yet explains all the clinical phenomena of
these interesting cases, and, in all probability, some of the variations
in the symptoms are to be attributed to differences in the character of the
disorder affecting the nerve trunks, or even to the nature of the causes
originating the active pathological condition.

Thus, when the ulnar nerve is frozen at the elbow, as has been done both
by Waller and myself, the temperature rises in the ulnar territories ; but,

Mitchell, Lesions of Peripheral Nerve-Trunks.

[Jul,

if the experiment be carried too far, and there is, as a consequence, total
loss of feeling for some days, the temperature falls and remains for a time
below the normal. Now the first effect from freezing is to cause com-
plete but brief loss of sense and motion, due to the fact that below a cer-
tain temperature, nerve-trunks cease to carry messages, and then the
temperature rises. If, however, according to Waller, the subsequent nerve-
changes, probably congestive in their character, be profound enough to
destroy the apparent power of the nerves, the temperatures fall. But
still more remarkable is it that when the loss of motion and feeling is
brought about experimentally by pressure on the nerve-trunks, there is
always a fall, and never a rise of temperature in the area fed by the
nerve-trunks thus acted upon (Waller).

Case V. Dislocation of Left Humerus into Axilla ; immediate and
increasing Nerve Lesions ; unusual Nutritive Changes resembling Abscess ;
Extravasation of Blood. — K. B., female, ret. 24, single, a worker on the
sewing machine, although delicate, was fairly well until August 1, 1882,
when she fell some three feet, and falling on the left side, with her arm
outstretched, found on rising intense pain in the left axilla, tingling to the
finger ends, and inability due to pain to allow the arm to fall in to the
side in a dependent position. So severe was the pain that an injection of
morphia merely lessened it, and no ease could be had except by bending
to the left so as to allow the arm to form a right angle with the body.
On the second day, there was marked weakness in the linger motions,
and the tingling became worse. On the sixth day, she came to the
city, where one of the surgeons of the Jefferson Medical College Clinic
promptly recognized and reduced the dislocation.

Nevertheless the pain and loss of power increased, and a month from
the date of the accident the back of the arm and hand began to swell,
especially on the ulnar side, and somewhat later the swelling extended to
the palm. At first this swelling looked like the not very rare pufliness
sometimes seen in the hand after a nerve lesion, but it soon became mottled
with extravasated blood, and presented a very threatening appearance,
which with varying amounts of pain, lasted until October, 1882, at which
time a large blister on the arm brought about a decisive change for the
better. As, however, the inhibition of movement due to pain grew less,
it became clear that the fingers were almost totally paralyzed.

In December, 1882, the interossei of the hand, and generally all the
muscles fed by the ulnar nerve, had wasted exceedingly. January 8, 1883,
the patient applied at Dr. Wharton Sinkler's clinic with these conditions.

Left arm somewhat wasted — great atrophy of the interossei — a typical
specimen of the " claw hand." There is the very common loss or
early return of sensation, it is now difficult to say which. Sensation is
nearly normal, except in the palmar surface of the hand and the fourth
or fifth digits where the skin is tense, shining, red, and exquisitely sen-
sitive, with a lessening amount of causalgia, while in the forearm only is
there constant aching. The swelling above described had totally disap-
peared, but the joint changes which are' usually limited to the fingers
affected also the wrist, elbow, and shoulder, and served to add to the
great difficulties of the case. The nails were deeply notched by nume-
rous transverse ridges.

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 31

Electrical Condition F. C. No response except in the following mus-
cles : flexor carpi radialis, flexor longus pollicis, and biceps. • The shoulder
muscles all respond well, except the deltoid which responds feebly.

G. C. No reaction in the intrinsic hand muscles, except in the adductor
pollicis and first dorsal interosseus. Muscles of forearm. No reaction
in the long extensors of the hand and fingers except in the exten. ossis
metacarpi pol. and ext. indicis ; these, together with all the long extensors
of the hand and fingers, are readily moved by the interrupted galvanic
current, but present a changed formula, indicating the reaction of degene-
ration, as follows : Ka. S. z An. 8. Z.

The biceps, triceps, and deltoid present only a quantitative lessening of
response.

The electro-sensibility is abnormally acute.

Ordered galvanism (interrupted) and massage on alternate days.

April 24, 1883. She has persevered in the treatment with regularity.
The arm is better in every way, so that she has now little or no pain,
and much more voluntary motion. All the muscles of forearm now
respond to the galvanic current, although but little change has taken
place in the short muscles of the hand.

The nerve lesions arising from dislocations are due rarely to the reduc-
ing process ; and much oftener as in this case to the injury caused by the
accident. In dislocation downward into the axilla, when the force is
great, with tear of the capsule and bruise or tear of the circumflex nerve,
there is apt to be also injury to the plexus, and in dislocations under the
clavicle or under the coracoid process the nerves seem also liable to suffer;
but of the liability to nerve-lesion in these several accidents there is yet
needed some more precise study. It will be found, I think, that in many
dislocations there are slight nerve-lesions, especially in the circumflex
nerve, and that their trifling nature has kept them from being noticed by
surgeons.

I do not think it very common to find the primary traumatic lesion
competent to produce very great loss of sense or motion. There is a little
numbness, the bone is replaced, and in a week or two, the secondary
changes in the nerve-trunks occasion increasing losses which may prove
enduringly disastrous.

Article II.

On Contusions of the Brain and of the Spinal Cord. By John A.
Lidell, A.M., M.D., late Surgeon to Bellevue Hospital, also late Surgeon
U. S. Volunteers, etc.

As the inner table of the skull may be fractured by the impact of solid
bodies upon the scalp, or upon the exterior of the skull itself, while the
outer table remains unbroken {see the number of this Journal for April,

32 Lidell, Contusions of the Brain and of the Spinal Cord. [July

1882, p. 325 et seq.). so the substance of the brain may be bruised,
crushed, or torn by external violence, and likewise may become stained,
infiltrated, or compressed with blood extravasated from its ruptured ves-
sels, while the osseous shell that envelops it sustains no perceptible
injury. But, inasmuch as the brain-substance is immensely more fragile
than the inner table of the skull, the last mentioned form of injury occurs
with immensely greater frequency than the first.

Want of space will not now permit an exposition of the principles or
laws of mechanics which are involved in the causation of such injuries,
although the subject is both attractive and important.

For the sake of enjoying clearness of view, it should be stated at the
outset, that the production of a contusion of the brain, or of the spinal
cord, is invariably attended with the production of a concussion of the
brain, or of the spinal cord, both forms of injury alike and simultaneously
resulting from the same display of external violence, and the former being
in the true sense of the word a complication of the latter. It is self-evi-
dent that any blow on the head or on the back, which bruises the brain
or the spinal cord, must also produce concussion (commotion) of the
bruised organ, at the same instant of time.

Moreover, contusions of the substance of the brain, or of that of the
spinal cord are, in reality, concealed wounds of these organs, which fre-
quently present many of the appearances or peculiarities that pertain to
lacerated wounds, just as external contusions, for instance those of the
scalp, are often found to do. But, speaking with more exactness, contu-
sions of the brain, and of the spinal cord, are solutions of continuity that
involve the elementary structures of which these organs are composed,
namely, the ganglion-cells, nerve-tubes, neuroglia, and bloodvessels ; and
they are met with only as complications of the concussions of these organs,
as stated above. These internal contusions, however, are injuries of
great importance. Leaving depressed fractures out of the reckoning,
wounds of the brain-substance in the shape of bruises fill a large space in
the domain of cerebral traumatisms; for, as cerebral concussions are
notoriously of very frequent occurrence, so also cerebral contusions, caused
by the very same external potencies, are not unfrequently met with in con-
nection with them.

And the experience gathered in the post-mortem rooms at a, number of
great hospitals, as well as in private practice, has shown that death from
uncomplicated concussion of the brain never takes place, and that contu-
sion of the brain is nearly always associated with concussion in the fatal
instances. More than fifty years ago, the now renowned Dr. Bright, of
Guy's Hospital, pointed out that in fatal cases of cerebral concussion there
might be found, not only minute extravasations of blood disseminated in
the substance of the brain, deeply as well as superficially, but also the
circumscribed patches which characterize contusions. {Medical Cases,

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 33

vol. ii. part i., 1831, p. 408.) Mr. Bryant says : " At Guy's Hospital,
during fifteen years, no case is recorded of death from concussion without
change of brain-structure." {Practice of Surgery, p. 161, Am. ed.
1879.)

Mr. Prescott Hewett, of St. George's Hospital, states : " That in every
case in which I have seen death occur shortly after, and in consequence
of an injury of the head, I have invariably found ample evidence of the
damage done to the cranial contents." (Holmes's System of Surgery, vol.
ii. p. 302, 2d ed.)

Mr. Le Gros Clark, of St. Thomas's Hospital, declares : " I have
never made nor witnessed a post-?nortem examination after speedy death
from a blow on the head, where there was not palpable physical lesion of
the brain." (Brit. Med. Journ., 1868.)

M. Fano, a French writer on the same subject, concludes : " That the
symptoms generally attributed to concussion are due, not to the concus-
sion itself, but to contusion of the brain, or to extravasation of blood."
(Mem. de la Soc. de Chirurg. de Paris, t. iii. p. 199.)

Moreover, there is but one case on record in which death having re-
sulted apparently from concussion of the brain, a carefully conducted
autopsy failed to reveal any lesion of the brain-substance ; but this patient
seems to have also had Bright's disease. The case, however, possesses
so much interest in this connection that it appears necessary to present a
brief account of it; Samuel L., aged 55, on September 23, at night,
was struck on the back of his head, a little to the right of the mid-
dle line, by a carriage ; he was knocked down, and the carriage went
over his legs ; no wound nor bruise on the head was noted. The acci-
dent was followed directly by violent headache, persistent and paroxysmal,
accompanied with great giddiness, diplopia, impairment of the senses of
smell and taste, and of the faculty of speech ; finally, hemiplegia of the
right side supervened, and death from coma occurred soon afterward, on
December 6th, at 3 A.M., on the seventy-fourth day after the accident.

Autopsy, forty-six hours after death " The convolutions looked healthy;

and no morbid appearance nor any softening, could be found in any part
of the brain. The corpora striata, optic thalami, fornix, corpus callosum,
and, in fine, every part of the brain, were examined carefully, both fresh,
and after preservation for a time in spirit ; and no morbid appearance
was detected anywhere. The cerebellum, pons, and medulla oblongata
were equally healthy." The legs were cedematous, having become so
shortly before death. The kidneys were slightly granular, and contained
a few small cysts, and some small masses of fibrine on their exterior.
The cortical structure was rather pale. (Brit. Med. Journ., Feb. 19,
1859, p. 145.)

The evidences of confirmed renal disease were revealed by the autopsy ;
and, doubtless, the peculiar symptoms and the fatal issue of this case were
No. CLXXI July 1883. 3

34 Lidell, Contusions of the Brain and of the Spinal Cord. [July

mainly due to the renal disease. And, had there been circumscribed
patches of cerebral oedema (which are liable to form in Bright's disease),
no trace of them might have been still visible so late as forty-six hours
after death, on the one hand; or, they might readily have been over-
looked, on the other. At any rate, this case (which was reported by
Prof. Parke), in consequence of being complicated with Bright's disease,
furnishes no exception to the rule that death from uncomplicated concus-
sion of the brain never occurs.

Finally, on reviewing with care the numerous clinical and post-mortem
observations of an exact nature which have been placed on record concern-
ing the injuries in question, especially in recent years, we reach two im-
portant conclusions which are fully sustained by the testimony: (1) That
whenever death results apparently from concussion of the brain, contusion
of the brain or some other complicating disorder is invariably present, and
that the fatal issue is always due to the complication, and not to the cere-
bral concussion itself. (2) That the complication which is almost invari-
ably present, in such cases, is bruising or contusion of the encephalon.

But, to what extent, or with what frequency, cerebral contusion occurs
in the cases of cerebral concussion which do not prove fatal, is an open
question. I can, however, unite heartily with Dr. Neudorfer, of the
Austrian Army, in declaring that I have never seen concussion of the
brain, properly so called, i. e., uncomplicated with contusion of the brain,
except in cases where the injury of the encephalon was trivial. Moreover,
in the few instances of concussion reported, wherein death has ensued
from other causes, some injury of the brain-substance has generally been
found ; and in all such instances wherein the fatal issue has resulted from
secondary inflammation, some evidence of contusion of the brain has like-
wise been found on examination post mortem.

That slight or even moderate concussions of the brain sometimes, per-
haps not unfrequently, occur without being complicated with contusions of
the brain, I do not doubt. Indeed, I shall by and by present .an example
in which there was a stunning in consequence, of a fall upon the head and
shoulders, that lasted some minutes, and death resulted about thirty hours
afterward from contusion of the spinal cord, yet no evidence of cerebral
contusion whatever was revealed by the autopsy. Contusion of the brain
is, therefore, not synonymous with concussion of the brain ; but, at the
same time, all the evidence now collected tends to prove that the severe
instances of cerebral concussion are always complicated with cerebral con-
tusion. Concussion of the brain, however, derives its chief importance
from the fact that it is very often associated with contusion of the brain ;
and, in examining a case of cerebral concussion, the question of most
importance for the surgeon to decide is whether or not cerebral contusion
is also present.

These are points of doctrine which practically have much interest for

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 35

patients as well as practitioners, because of the influence they are likely
to exert in the direction of procuring a correct diagnosis and, consequently,
a wise treatment ; for, in the disorders of no other parts of the body is it
more true that an accurate diagnosis begets a wise plan of treatment than
in those of the brain and spinal cord. Inasmuch as it is the mechanical
injury — the disintegration and rupture of the brain-substance, and its blood-
vessels— or the hemorrhage resulting therefrom, which in reality do the
harm in nearly all the cases of cerebral concussion, unattended by frac-
ture, that give trouble, or do badly in any way, these lesions of structure
and their consequences are the things which ought to receive principally
the surgeon's attention while conducting the treatment of such cases ; and
should he have previously made himself thoroughly familiar with the sub-
ject of cerebral contusions as almost the sole complications of the cerebral
concussions that are without fracture, and with the various consequences
which immediately or remotely result from these lesions of the brain-struc-
ture whether attended or unattended by fracture, he will be very much less
liable to adopt a mistaken, incorrect, or inefficacious plan of treatment,
whenever such cases shall come under his care.

Nevertheless, our text-books on surgery, with but few exceptions, and
likewise most of our lectures on surgery (as there are good grounds for
fearing and believing), either do not discuss contusions of the brain at
all, or they do it in a very inadequate manner — one quite unworthy of the
subject. While much is said by all of them on the subject of cerebral
concussion — of its dangers and of its importance — but small if any men-
tion is made, excepting by the praiseworthy few, of the contusions of the
brain which so very often complicate the concussions, and impart to them
whatever of gravity, be it much or little, that they may chance to possess.
And still less mention is made of the contusions of the spinal cord. No
wonder, then, that bruises of the brain-structure, and of the spinal cord-
substance, occur much more frequently than is generally supposed, that
the relationship which exists between these injuries and concussions is not
well understood in the profession at large, and that the bruises of these
organs often escape all notice, and even all suspicion, during life. An
article on contusions of the brain, and of the spinal cord, may therefore
prove timely and serviceable.

Before presenting some examples, whereof I have preserved the notes,
as well as some others, it may be advisable to premise in a general way, as
follows : (1) Whenever contusion of the brain is produced, the lesion of
the brain-substance is usually found either directly underneath the scalp-
wound, ?'. e., directly underneath the external point of impact, or on exactly
the opposite side of the encephalon. The latter often occurs, and is truly
said to be caused by the contre-coup. (2) Bruises of the cortical portion
of the brain and pia mater, when exposed to view, oftentimes do not dif-
fer much in appearance from bruises of the subcutaneous connective tis-

36 Lidell, Contusions of the Brain and of the Spinal Cord. [July

sue, for both injuries alike are attended by ecchymosis. In numerous
instances, however, there is a much more copious extravasation of blood,
in cases of cerebral contusion, than that which occurs in ordinary ecchy-
mosis. and not unfrequently this extravasation proceeds so far as to
cause death, per se, by compressing the brain. Such sanguinolent extra-
vasations are met with, (a) beneath the so-called visceral arachnoid mem-
brane, i, e., in the meshes of the pia mater, and furrows of the brain ; (b)
in the so-called cavity of the arachnoid membrane,1 i. e., on the free sur-
face of that membrane; (c) in the ventricles of the brain ; (d) to the fore-
going must be added those minute extravasations of blood (having the
size of millet seeds), which are occasionally found disseminated in great
numbers through the brain-substance, deeply as well as superficially. (3)
Bruises of the brain often cause traumatic encephalitis, which eventuates
cither in subsidence and recovery, or in suppuration and cerebral abscess,
or in permanent disturbance of the mental faculties, sometimes accompa-
nied also by epileptiform convulsions.

I shall now proceed to point out what never has been clearly shown
before, the intimate relationship which exists between cerebral contusions
and the formation of cerebral abscesses.

Case I. Contusion of the Cerebrum complicating Contusion of the Scalp
caused by a Spent Bullet ; Adhesive Meningitis; Cerebritis and Cerebral
Abscess; Death; Autopsy. — Colonel Noah L. F., while convalescing
from camp fever, was wounded at the first battle of Bull Run July 2J,
1861, by a spent musket-ball, which contused and lacerated (slightly) the
outer layers of his scalp, over the left parietal bone, three inches above
the auditory meatus. He was much stunned, and fell from his horse.
On the 24th, he was admitted to the Washington Infirmary, where the
present writer saw him ; the scalp-wound was half an inch in length,
quite superficial, and already nearly healed. On the 26th, numbness of
his right hand was noted, all the fingers being equally involved. On the
28th, his right foot also became numb. Two days later, paralysis of
motion in these parts ensued. There was headache at this time, but it
did not. appear to be a very marked symptom. The wound healed
promptly, no febrile movement was noted, and his condition was con-
sidered a hopeful one, i. e., it was thought he would recover, until August
10th, when grave cerebral symptoms with hemiplegia (of the right side)
appeared. Coma followed, and in that state lie died on the 14th, having
survived the contusion twenty-four days. It was then remembered that
he had been irritable, morose, much inclined to keep his bed, and just
before the final seizure had complained much of headache.

At the autopsy (made on the 15th), we found that the external wound
was quite superficial; that the skull was not injured; that there was a
copious subarachnoid serous effusion (pale) in the meshes of the pia
mater; that there was a considerable quantity of yellowish serum in the
ventricles ; and that there was an abscess in the cerebrum, directly under-

1 The so-called parietal arachnoid has clearly been shown by anatomical investiga-
tions, conducted with the aid of the microscope, to be the internal or epithelial layer
of the dura mater, and not an independent membrane or structure.

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 37

neatli the scalp-lesion. This abscess was about as large as an English
walnut, seated superficially, and surrounded by softened cerebral tissue.
Over it, the arachnoid membrane was glued to the dura mater, to some
extent, by adhesive inflammation (circumscribed meningitis traumatica),
so that in turning back the dura mater, though carefully done, the abscess
was torn open. There were also distinct traces of an irregularly circum-
scribed extravasation of blood from small vessels (ecchymosis), apparently
three or four weeks old, found in the cerebral sulci and cortex above the
abscess, i. e., directly beneath the scalp-injury; and, likewise, at the an-
terior extremity of the left cerebral hemisphere. There was, too, a flat-
tened clot of blood, black in colour, and apparently three or four weeks old,
found on the free surface of the arachnoid, in the fossa, at the base of the
middle lobe of the same hemisphere. The dura mater in relation with it
was somewhat thickened, roughened, and opacified. To Professor J. W.
S. Gouley the present writer was indebted for an opportunity to see this
patient during life and to witness the autopsy, as well as for a number of
very important notes concerning the progress of the case, which have never
before been published.

In this example the symptoms which arose from the cerebral contusion
were irritability, moroseness, headache, loss of sensibility beginning in
the right hand and fingers three days after the casualty occurred, loss of
sensibility in the right foot two days later, and motor as well as sensory
paralysis in these parts appearing two days still later, together with steadily
increasing hemiplegia after that time. The proximate cause of these
symptoms was inflammation ending in suppuration (abscess) of the bruised
cerebral tissue. At the present day, scarcely any surgeon acquainted with
the subject of cerebral contusion, and the liability of this form of injury
to cause cerebral abscess, would fail to make a correct diagnosis while
watching the progress of such a case ; and, in the absence of any scalp-
wound, the doctrines of cerebral localization would inform him with cer-
tainty as to the locality of the abscess. Had the nature of the cerebral
lesions been correctly surmised in the example just related, and had the
operation of trephining the skull underneath the scalp-lesion, and evacu-
ating the abscess by puncture or aspiration, been seasonably performed
with antiseptic precautions and antiseptic after-treatment, it is not im-
probable that the patient would have recovered. For Dr. Obalinski re-
lates in the Wiener Med. Woch., No. 44, a successful case of trephining
which apparently belongs to precisely the same category. It occurred in
a man, aged 45, who, two weeks after a wound of the head, on the left
side, showed gradually increasing paralysis of the right side (hemiplegia),
with augmented knee-phenomenon and some rigidity of muscle. On
careful consideration, it was deemed fit to perform the operation of tre-
phining, as it was thought probable that the symptoms mentioned were
due to an abscess of the brain. The operation was done antiseptically.
The dura mater was incised, some yellow matter escaping; the cavity was
washed out with a one per cent, solution of thymol, drained and dressed.
Some reaction followed and lasted a few days, but the patient's uncon-

38 Lidell, Contusions of the Brain and of the Spinal Cord. [July

sciousness and the other head symptoms soon subsided, and he left the hos-
pital at the end of nine weeks. The paralysis and rigidity had then entirely
subsided. {Medical News, December 30, 1882, p. 735), also {Med. Times
and Gazette, December 2, 1882.) It is therefore clear, that, at the present
day, cases of cerebral abscess arising from cerebral contusion should not
be left to perish from cerebral compression, without making an attempt to
save them by performing the operation of trephining and evacuating the
abscess.

It is barely necessary lo add that, in the pathological history of this
case, as disclosed by the autopsy, there resulted from the bruising and
ecchymosis of the cerebral cortex, (1) adhesive meningitis; (2) circum-
scribed encephalitis of a suppurative character; (3) a cerebral abscess,
which caused death by compressing the brain.

Case II. Severe Concussion and Contusion of the Brain, caused by
falling: Encephalitis; Coma; Death; Autopsy: Fissured Fracture of Skull;
Ecchymosis of Cerebral Convolutions ; also Diffused Subarachnoid Hemor-
rhage ; Cerebral Abscess in the form of a so-called Cerebral Ulcer

Mr. C, aged about 30, was knocked down October 3, by a strong blow-
on his breast, his head striking the stone pavement. He was picked up
completely insensible. Thirty-six hours afterward he recovered con-
sciousness sufficiently to tell where he lived, and many facts concerning
his injury. He was carried home, where he lingered with the symptoms
of irritation and inflammation of the brain, until the 9th (/. e., six days
after the injury), when he died comatose.

Autopsy,, by the writer, twenty-four hours after death. — Beneath the
scalp on the right parieto-occipital region, a considerable quantity of biood
was found diffused in the loose connective tissue under the occipito-fron-
talis. In the same region there was a fissured fracture of the skull, with-
out displacement. Beneath the visceral arachnoid membrane, over all the
right hemisphere of the cerebrum, blood was found extravasated in the
meshes of the pia mater, so as to fill more or less completely the furrows
between the convolutions of this part of the brain. Underneath the frac-
ture, the convolutions themselves presented a bruised or ecchymosed ap-
pearance. A black clot of blood, somewhat larger than an almond, and
flattened in shape, was found at the base of the middle lobe of the same
hemisphere, and the parts of the arachnoid and pia mater in contact with
it were so much disorganized that I could not determine whether this ex-
travasation had occurred beneath the arachnoid or upon its free surface.
The cerebral substance alongside this clot was much softened to the depth
of nearly an inch, and so much disorganized that no organized structure
could be discerned with the unaided eye. It was yellowish in colour,
and puriform in consistence. Another, but a smaller coagulum was found
at the base of the anterior lobe of the same hemisphere. This clot seemed
from colour and consistence to have had a more recent origin than the
other clot. The cerebral substance alongside exhibited white softening.
The right lateral ventricle contained about twTo drachms of sero-sangui-
nolent liquid ; the left about half a drachm. The dura mater was not
injured, and no blood was effused between it and the fractured bone. (See
also the number of this Journal for January, 1880, pp. 95, 96.)

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 39

The essential injuries in this example were the concussion and the con-
tusions of the brain ; for the cranial fracture produced no symptoms, and
exerted no influence whatever on the result. In this, as well as in the
preceding example, the cortex of the cerebrum, at a point corresponding
to the bruise of the scalp, presented an ecchymosed appearance through
an irregularly circular space, in consequence of numerous small extrava-
sations from minute bloodvessels which had been ruptured by the force of
the blow thai was communicated to the brain.

But there was another patch of contused brain-substance, which was
found on the base, or under surface of the middle lobe of the right cerebral
hemisphere. Here, the bruised part had a depressed and shaggy surface,
with sharp irregular borders, and looked not unlike an ulcer, such as has
in fact been described by some surgeons " as the traumatic ulcer of the
brain." The softened brain-tissue in relation with it had a puriform con-
sistence and a yellowish colour, which were due to traumatic circum-
scribed encephalitis and infiltration of the inflamed part with pus-cor-
puscles. In other words, there was a superficial abscess of the brain. In
respect to causation, the bruising of this patch of brain-substance must
have been produced by contre-coup, i. <?., the bruised part must have been
violently thrown against the middle fossa of the cranial base by the great
force of the external blow.

Next, I shall present a case in point taken from Circular No. 3, which
was issued by the Surgeon-General, August 17, 1871, and is a report of
surgical cases treated in our army during the previous five years. In
the sequel, I shall likewise present several other cases taken from the same
source, because they are of intrinsic value, per se, and at the same time
are not readily accessible to most readers.

Case III. Cerebral Contusion ; Cerebral Abscess ; Death; Autopsy

Private C. M-, musician, 27th Infantry, was entered on the sick report at
Omaha Barracks, March 11, 1869, as suffering from contusion around
both eyes, with partial detachment of the cartilage of the septum nasi and
resultant flattening of the nose — produced by a blow with the fist. The
injury was attended with a good deal of epistaxis. By March 17th, he
had much headache, with constipation, and the appearance of manifest
debility. Active treatment was resorted to ; the patient's condition varied.
Death occurred suddenly on the night of April 1st, 21 days after the injury
was inflicted.

Autopsy A small quantity of pus was found in the foramen caecum and

in the grooves for the bulbs of the olfactory nerves. The crista galli was
broken off, and its apex turned toward the left. Purulent matter was
found in the meshes of the pia mater on the base of the brain for three-
fourths of its extent. There was a longitudinal slit in the cerebraLmem-
branes with dark edges, three-eighths of an inch in length at the anterior
end of the corpus callosum, one-sixteenth of an inch to the left of the
longitudinal li-sure. On detaching the membranes at this point, a sinus
was found leading to an abscess in the left anterior cerebral lobe, which
proved to be as large as a hen's egg. It was filled with pus, broken-down

40 Li dell, Contusions of the Brain and of the Spinal Cord. [July

cerebral substance, and on its outer wall contained dark (/ruinous matter.
It communicated with the anterior cornu of the left ventricle. Both
lateral ventricles, together with the third ventricle (through the foramen
of Monro), and the fourth ventricle (through the aqueduct of Sylvius),
were all distended with pus and disintegrated cerebral substance, with
some serum. The lining of the fourth ventricle had a dusky-red colour.
{Op. cit., p. 123.)

The sudden termination of this case in death apparently was due to
bursting of the cerebral abscess which had been formed in the anterior
lobe of the left hemisphere, whereby all the ventricles of the brain speedily
became filled up with purulent matter. That death did not occur at an
earlier date (for the man survived his injuries three weeks) was probably
due to the fact that the cerebral abscess had an external outlet through a
narrow sinus, which, however, was liable to become choked with blood-
clots and disintegrated brain-tissue. Moreover, any purulent matter which
had made its way into the arachnoid cavity could readily escape from the
skull through the part of the ethmoid bone from which the crista galli was
broken off.

What caused the cerebral abscess itself? The presence of dark grumous
matter within its cavity clearly indicates that its formation had commenced
with an extravasation of blood ; and this circumstance taken in connection
with the blow on the head, which caused the disability, denotes that some
small bloodvessels within the left anterior lobe of the cerebrum were rup-
tured by the vibrations of the brain-substance which resulted from the
blow ; or, in other words, that the cerebral substance at this point was
contused by the same application of force which contused the external parts,
with the usual consequences thereof, namely, ecchymosis and sanguinolent
extravasation, developed internally as well as externally. Suppurative en-
cephalitis ensued, and a cerebral abscess was formed.

Did space permit, I would present at length several additional examples
in which cerebral contusions eventuated in cerebral abscesses, some of
which were saved by the operation of trephining, and discharging the puru-
lent matter. There is, however, no doubt that cerebral contusions very
frequently give rise to cerebral abscesses.

But, does the traumatic encephalitis which arises from cerebral contu-
sions always eventuate in suppuration ? By no means ; for, although this
variety of brain-inflammation is a disorder of great frequency and corres-
ponding importance, it very often, perhaps generally, proves amenable to
timely treatment of an appropriate nature, as the next six examples will
serve to show.

Case IV. Severe Concussion and Contusion of the Brain produced
by falling Headforemost about seventeen feet; Recovery. — Anne G.,
aged 10 years, and always healthy, was precipitated headforemost into the
coal cellar of a neighbour's house, by the sudden breakage of a wooden
railing against which she happened to lean, on the afternoon of September
12, 1866. She fell a distance of about 17 feet, and struck the stone bottom

1883.] Lidell, Contusions of -the Brain and of the Spinal Cord. 41

of the cellar with her head and shoulders. She was picked up completely
insensible, and carried home in that condition.

I was called to this patient for the first time, on the loth, i. e., three
days after the accident. I found her feverish and restless, with an excited
pulse, a hot skin, a furred tongue, a flushed countenance, contracted pupils,
and complaining of intense headache, together with intolerance of light
and sound, or, in other words, she exhibited the usual symptoms of severe
inflammatory irritation of the brain, or encephalitis. Her head was warmer
than the other parts of her body. On her forehead the external marks of
an extensive bruise were plainly seen. She said her shoulders and back
were sore, and she was indisposed to move or to allow herself to be moved
on that account. A careful examination, however, showed that no part
was paralyzed, and that no bone was broken. Her mother (by the way,
she was a lady of more than ordinary intelligence) informed me that when
she was brought home, soon after the accident, her face, eyes, ears, nose,
and mouth were filled with coal-dust, that blood was flowing from her
nose and mouth but not from her ears, that she remained insensible for
many hours afterwards, that she vomited repeatedly during this time, that
her skin was cold, and that she had not fully come to herself since the
accident. Her mother also informed me that she did not rest well, that
her sleep was disturbed by what appeared to be frightful dreams, which
caused her to cry out, not unfrequently ; that her disposition which norm-
ally was very amiable, had become fretful, sullen, and morose, and that
she complained much of pain in her head. The patient had been kept
quiet, and cold applications had been made to her head previous to my
visit. A dose of Epsom salt had also been administered, which operated
well, and afforded some relief. Prescribed the following liquid and pow-
ders : R. Tinct. radicis aconiti, gtt. xij ; aquoe destillat. f^ij. S. Give
one teaspoonful every 4 hours. R. Hydrarg. cliloridi mitis, gr. ij ;
sacchari albi, 9j. Misce bene, et fiant pulv. No. 8. S. Give one powder
every 4 hours. Ordered the head to be constantly kept wet with ice-water ;
enjoined quietude, both mental and physical, as nearly absolute as possible,
and allowed no food besides oat-meal gruel.

l&th. All the symptoms are better; but the bowels having not acted
since the previous day, I prescribed Epsom salt §ss, and directed the
other treatment to be continued.

17th. The headache and other symptoms of cerebral inflammation have
nearly disappeared. She is quite cheerful, and says she feels pretty well.
Suspended medication, excepting prophylaxis, but directed that her symp-
toms should be closely watched, that she should not be sent to school again
for the next, three months, and that I should be informed immediately if
the headache or any other symptom of cerebral irritation returned. This
patient apparently made a good recovery ; but her sleep did not become
entirely natural until more than three months afterward.

Moreover, her tendency to headache, resulting from the cerebral contu-
sion, has never entirely disappeared. Oftentimes, since her misadventure,
she has been a martyr to cephalalgia for months. Within the last year, I
have been called upon by the patient to combat, with remedies, this symp-
tom of ancient cerebral injury. She says she has never been quite free
from headache since the accident occurred.

The diagnosis of cerebral contusion, as well as that of concussion in this
case, was founded upon the fact that the subject fell a great distance, fully

42 Lid ell, Contusions of the Brain and of the Spinal Cord. [July

seventeen feet, upon her head, and that, ipso facto, bruising of the brain-
substance must, under these circumstances, always occur. Moreover, en-
cephalitis ensued, as the symptoms clearly denoted, which could not have
appeared unless there was a contused wound (bruise) of the brain itself.
There was also nasal hemorrhage ; and, surely, a blow on the skull strong
enough to make the nose bleed must, ex necessitate, produce bruising of the
brain.

Case V. Strong Concussion and Contusion of the Brain produced by
falling Headforemost about thirteen feet; Recovery. — G. X., a fine
healthy boy, in the sixth year of his age, lost his balance near the top or'
a high flight of stairs, and fell over the balustrade down into the hall,
striking the marble floor thereof with his head so forcibly as to jar the
whole house. He fell a distance of about thirteen feet. He was taken up
immediately and placed in bed insensible. The accident occurred on
Saturday evening, November 3, 18GG. Within an hour afterward I saw
the patient ; was informed that he had lain insensible all the time since
the injury, and, furthermore, that he had vomited. I found his counte-
nance pale, skin cool, pulse slow and weak, and he lay unconscious with
his eyelids closed, as if he were in a deep sleep. He could, however, be
aroused sufficiently to answer a few simple questions, but even this awak-
ening could not be accomplished without much difficulty. Both pupils
were widely and symmetrically dilated ; but no voluntary muscle was
found to be paralyzed. The scalp ivas extensively bruised on the right
side of his head. Directed sinapisms (mild) to be applied to his feet and
legs, warm flannel to be wrapped around his body, and warm tea (Chi-
nese) to be given internally. Under this treatment the symptoms of
shock gradually disappeared ; and, in the course of about three hours, a
moderate amount of vascular reaction occurred. Then I directed his head
to be kept constantly wet with cold water, his room to be kept entirely
free from noise, and prescribed a low diet, together with the following
powders : R. Hydrarg. chlorid. mitis, gr. j ; sacchari albi, gr. xx. Misce
bene, et divide in pulv. No. 8. S. Give a powder every three hours.

4th, morning. He has rested well ; still complains of headache and sore-
ness of his shoulders and back ; but he does not remember anything that
occurred last night. Directed the same treatment to be continued.

5th. All the symptoms are better ; but the headache has not yet entirely
disappeared. Prescribed sal Eochelle, 3 i v- iQ sugar- water.

6th. Improving, but he is still rather dull, and has some headache.

7th. He is bright and cheerful, and free from pain. After this time,
apparently, no difficulty remained. However, I directed his parents to
inform me, without delay, should the headache or the restlessness, or any
other unpleasant symptom return ; and I discontinued my visits.

I shall barely add that the diagnosis of cerebral contusion, in this
example, was based mainly upon the enormous severity of the blow which
the patient's head sustained.

Case VI. Cerebral Contusion caused by a Violent Blow on the Head ;
the Symptoms continued nearly three months; Recovery. — Emory B. C,
a commercial agent, aged about sixty, but of large size and strong build,
was crushed senseless down to the floor of a hall-way through which he
was passing, on January 21, 1832, by the sudden fall upon his head of a

1883.] Lid ell, Contusions of the Brain and of the Spinal Cord. 43

large piece of thick old plaster-work, estimated to weigh above one hun-
dred pounds, which had suddenly become detached from a cerling that was
sixteen feet high. The blow was so strong that two of his teeth were
loosened, and a third was broken off by it. His back and loins were also
severely strained. He received a lacerated and contused wound of the scalp,
two and one- half inches long, over the right parietal bone. He was severely
stunned, and did not come to himself for some time. When I saw him,
about two hours after the accident, he was still rather dull, as well as very
pale, with a cool skin, and a slow, weak pulse. The scalp-wound was
dressed with emplast. adhesivum, and quietude as nearly absolute as pos-
sible enjoined. The next day there was headache and other signs of cere-
bral irritation, with constipated bowels ; advised the continuance of quie-
tude, a spare diet, the application of cold water to his head, and a dose
(^j) of Epsom salt. But the cerebral irritation proved to be persistent.
The symptoms were headache, both general and local, inability to sleep
(insomnia), though constantly somnolent, sleep disturbed while it lasts by
dreams, constipation, a slow, full pulse, contracted pupils, a suspicious
look, an altered disposition, i.e., he became morose and irritable instead
of being companionable and agreeable, incapacity to read understanding^,
together with giddiness, and a constant feeling of a heavy weight pressing
on his brain. These symptoms persisted a long time, and but gradually
disappeared. The treatment consisted in quietude of both body and mind,
the use of a meagre diet, the administration of enough sal Epsom or sal
Rochelle to obtain two alvine discharges per diem, and the application of
cold water to the head.

On February 16th the following was prescribed : Hydrarg. chlorid. cor-
rosiv. gr. ij ; tinct. gentian, comp. ^iv. Misce et solve. Signa. One
teaspoonful three times a day, mixed in water. The use of this remedy
was continued, with manifest benefit, for nearly six weeks.

On March 29th potassium iodide was prescribed in doses of ten grains
in lieu of the corrosive chloride of mercury.

On April 20th I discontinued my attendance, as he had fully recovered ;
and he has remained well ever since.

The diagnosis of cerebral contusion, in this example, was based mainly
on the character and persistence of the cerebral symptoms, for nothing
less than a severe lesion of the brain-substance would have produced them.
The plan of treatment prescribed was executed with great exactness ; and
had the treatment itself been much less active, or much less thoroughly
executed, suppurative encephalitis and cerebral abscess would pretty cer-
tainly have ensued.

The next three examples will serve to emphasize two important facts :
(1) that all severe concussions of the brain are very apt to be complicated
with contused wounds (bruises) of the brain-substance ; and (2) that such
wounds of the brain-substance are in turn very apt to eventuate in cere-
bral inflammation or encephalitis.

Case VIT. Severe Concussion and Contusion of the Brain; Encephalitis;
Imperfect Recovery. — Private W. 11. B., Co. I, 40th Infantry, received July 2,
1867, at Fort Macon, at the hands of an escaping prisoner, two blows upon the
front and right side of his head, above the temporal ridge, struck with a ham-
mer, producing a scalp- wound, and, no doubt, contusion, as well as severe con-

-44 Lid ell, Contusions of the Brain and of the Spinal Cord. [July

cussion of his brain. He lay in a comatose state for several hours. After reac-
tion appeared, appropriate treatment was prescribed. There was no discernible
fracture. The scalp-wound readily healed. But the man suffered from head-
ache, giddiness, loss of memory, impaired vision, confusion of thought, and was
very dull of comprehension. To a casual observer, his recovery would appear
complete ; but the injury had left his brain in a state so unstable that it was liable
to be disturbed by even a very slight excitement ; he was, therefore, discharged
from the service on August 21, on surgeon's certificate of disability. (Circular
No. 3, S. G. 0., August 17, 1871, p. 110.)

This case also serves well to illustrate the kinds of injury which are
more especially liable to be attended by circumscribed contusions of the
brain-substance, to wit, blows on the head inflicted with instruments of
small compass, such as hammers, spent balls, stones, brick-bats, etc. ; and,
in such cases, the brain-wounds will usually be found situated directly
underneath the point of impact of the vulnerating force upon the exterior
of the skull.

Case VIII. Severe Bruising of the Brain ; Violent Encephalitis ; Recover//
in four months. — Private S.. Co. H, 3d Infantry, was admitted to the post-hos-
pital at Fort Dodge, November 17, 1868, having been knocked down by another
soldier, and severely kicked and trampled upon about the head and face. The
zygomatic process of the temporal bone and the nasal bones were fractured, and
there was cerebral concussion of an aggravated character. When admitted, there
was complete prostration of all nervous and physical powers. The means em-
ployed to bring on reaction, though used for an hour or more, seemed of little or
no avail. His condition remained unchanged for eight or ten hours ; shortly after
midnight, when aroused and spoken to, he answered, but immediately relapsed into
his former condition. On the morning of the 18th he appeared somewhat relieved ;
was aroused more easily, and, when sharply spoken to, would give unintelligi-
ble or irrelevant replies. His face was greatly distorted by the swelling, his
eyes completely closed, and there were several cuts upon his forehead and face.
During the day violent inflammatory symptoms, pointing to brain-trouble, set in.
He became exceedingly restless, and tossed himself about so violently that it was
necessary to hold him down in bed ; cold applications were made to his head, a
sinapism was put on the back of his neck, and a blister behind each ear. This
condition lasted about five days, when he gradually became more calm; but his
mental faculties were much impaired. During December and January, however,
he slowly improved, and in March. 1869, he was returned to dutv. (Ibid.,
p. 124.)

Concerning this example, it is worthy of special remark that the symp-
toms of cerebral contusion presented themselves in an unusually distinct
manner; for there was " complete prostration of all nervous and physical
powers" (?'. <?., intense shock), which lasted some eight or ten hours or
more, then somnolency or hebitude with incoherence for several hours,
followed by extreme restlessness and wild or violent tossings of the body,
which were with much difficulty restrained. In respect to the symptoms,
this example may justly be considered as typical.

Case IX. Contusion as well as Concussion of the Brain ; Recovery. — Private
P. E., Co. B, 42d Infantry, was brought to hospital at Plattsburg, X. Y., about
6 o'clock P. M., April 9, 186 7, in an unconscious condition, and bleeding pro-
fusely from a wound of the head, |3roduced by a blow from a musket in the hands
of an intoxicated soldier. On examination, a lacerated wound, one inch in length
and one-fourth of an inch in depth, was found on the right orbital ridge ; also, a
slight tumefaction in the right temporal region. Blood was slowly oozing from

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 45

his nose and mouth ; his eyes were turned upward and fixed ; pupils contracted
and insensible to light ; pulse feeble ; countenance pallid ; surface 'of body (skin)
cold. His breath had a decided alcoholic odour, indicating that some degree
of inebriation might be present. The treatment consisted in applying a sinapism
to the spine, with bottles of hot water to the feet and body, and cold water to the
head. At 11 o'clock there were symptoms of reaction; he answered questions,
though rather confusedly, and complained of great pain in his head. He was
kept quiet, and the treatment continued. He slept a little during the night, but
was restless at intervals. The next morning he appeared quite sensible ; pulse
76, and stronger ; skin hot and dry ; considerable thirst, and no appetite ; com-
plained of some frontal headache. Continued cold water to his head, and gave
potassic nitrate, <jr. iv, every two hours. During the day, the febrile symptoms
subsided, and during the night he slept without interruption. Henceforth, this
soldier rapidly improved; on the 18th he was dismissed from hospital and
returned to duty. (Ibid., pp. 110, 111.)

Dr. Samuel Wilks, of Guy's Hospital, has reported the following exam-
ple, which will answer well to illustrate the possible consequences (remote)
of cerebral contusions, and the post-mortem appearances of the bruised
cerebral tissue after the lapse of several years : —

Case X. "Epilepsy ; Old Injury of the Brain. — A man, set. 43, was admitted
suffering from epilepsy. Between two and three years before he had fallen on
the back of his head, and, a year before, he had had a fit for the first time. On the
morning of his admission it was observed by his fellow-workmen that his appear-
ance underwent a sudden change, that his face became contracted, and that blood
rloAved from his mouth. He afterwards had another fit, and was brought to the hos-
pital. He was then quite insensible, the pupils dilated, the respiration labouring,
the cheeks blown out, etc. The fits continued with scarcely any intermission ; he
afterward appeared to be paralyzed on the left side. The post mortem showed
clearly that the brain had at one time received a severe contusion ; the surface of
the anterior part (which would suffer from contre-coup~) presented a brown or
ochrey colour from effused blood. This condition extended into the cineritious
substance. The anterior lobe was adherent to the dura mater, and so was the
under surface of the left lobe." (Guy's Hospital Reports, 186G, p. 233.)

The epileptiform convulsions and chronic cephalalgia terminating in
death by coma, and the post-mortem lesions which characterized the
bruised brain in this case, do not seem to require any additional remark.

But, before leaving this branch of the subject, a brief paragraph should
be devoted to an important class of cases, much less acute than the fore-
going, which, hitherto, have received but scanty mention. For instance :
A labourer receives a blow on the head from the sharp corner of a stone
or a brick-bat, which knocks him down. He is considerably stunned for
the moment, but soon rallies, and gets up without assistance. His scalp
is found to be slightly wounded, but there is no fracture. Although he
has considerable pain in the injured part, and is quite giddy, he at once
returns to his work ; and, although his headache, etc., persist, he still
'continues to work. The wounded scalp readily heals. He goes on in this
way some two or three weeks, perhaps longer ; then he suddenly becomes
seized with intense cephalalgia and rigours, rapidly followed by hemiplegia
and coma ; or, the paralysis and insensibility may supervene without
rigours and without any great increase of headache. Death soon ensues,
and the autopsy reveals directly beneath the cicatrix of the scalp-wound

46 Lidell, Contusions of the Brain and of the Spinal Cord. [July

the traces of a circumscribed ecchymosis in the pia mater and cortical
substance, and deeper still a cerebral abscess. Such cases are reported
from time to time ; and it is my belief that they are much less rare than
is generally supposed. Moreover, such cases may be saved by the opera-
tion of trephining and evacuating the abscess by puncture or aspiration,
as has been done with success in analogous instances by Dr. J. F. Weeds,
by Mr. Holden, and by Mr. Hulke, as well as by Dr. Obalinski, as stated
above ; especially if antiseptic precautions, and antiseptic dressings (with
adequate drainage) be also employed. In all such cases, a much more
considerable bruising of the brain has occurred than the degree of cere-
bral concussion would at first seem to imply.

In the example which was last related the contusion of the brain-sub-
stance was produced by contre-coup, i.e., it occurred on the side of the head
opposite to that which struck the ground in falling. This circumstance
brings fairly before us the whole subject of cerebral contusion by contre-
coup ; and I propose to present next whatever facts concerning it may
seem to be possessed of practical importance.

Hennen relates a case in which contusion of the brain by contre-coup
was produced by falling on the head : A soldier, " being very much
intoxicated, fell from the top of the stairs leading to his barrack-room,
consisting of seventeen steps," on the night of December 5, 1818. He
was picked up " in a state of complete coma;" pulse u slow, full, and
strong, but very irregular ;" pupils natural ; breathing " in some degree
stertorous," being performed, "as is frequently done in sleep, through the
nose, but with the mouth open." There was "a small lacerated wound"
in the scalp over the posterior superior part of the right parietal bone,
"but without any tumefaction to prevent the most accurate examination
of the subjacent bone. Neither at this point nor any other can any frac-
ture or depression be discovered in the bone." Nevertheless, he sank and
died on the night of the 7th, without recovering consciousness.

Necroscopy. — The only mark of violence which appeared externally was
the small scalp-wound just mentioned, with some bleeding from the nose
and right ear.

u The upper part of the cranium being removed in the usual manner,
discovered that portion of the dura mater lining the left half of the frontal
bone (and which was diametrically opposite to that in which the wound
in the external integuments was situated), tensely distended, and of a deep
purple colour from the blood effused underneath it. The upper portion of
the dura mater being removed by a circular section corresponding with
that of the bone, a very considerable quantity of coagulated blood was
found upon this part of the surface of the brain, and part of the cerebral
substance itself appeared disorganized, and blended with this grumous
mass."

The autopsy also revealed much bruising of the right temporal muscle,

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 47

and extensive fractures of a fissured character in the right temporal and
parietal bones, with a considerable quantity of blood effused between these
bones (especially the former), and the dura mater lining them. No
derangement was to be discovered in the internal structure of the cere-
brum or cerebellum. (Principles of Military Surgery, pp. 265-267,
Am. ed.)

In this example the contusion of the cerebral substance by contre-coup
was very well marked ; for the anterior lobe of the left cerebral hemi-
sphere, at a point directly opposite the scalp-wound over the posterior
part of the right parietal bone, was so much disintegrated by the force of
the counter -stroke that it " appeared disorganized, and blended with the
grumous mass" of extravasated blood which covered it, the extravasation
being collected in very considerable quantity in that part of the left arach-
noid cavity, as well as in the meshes of the pia mater at the place of
cerebral injury, the visceral arachnoid itself being lacerated.

The proximate cause of this man's death was compression of the brain
produced by extravasated blood. The compression of the left cerebral
hemisphere was exerted by the blood which had been effused into the
cavity of the left arachnoid membrane, and into the corresponding furrows
between the cerebral convolutions, from the torn and crushed vessels of
the parts of the pia mater belonging to the focus of cerebral contusion.
The compression of the right cerebral hemisphere was produced by the
blood which had been poured out into the space between the right tempo-
ral and right parietal bones, and the dura mater underneath them, from
the middle meningeal artery (or its branches)' which had been torn open
by the fissured fractures of these bones. These fractures were not recog-
nizable during life because they were not attended with depression, nor
any displacement.

The lesions revealed by the autopsy satisfactorily explain the symptoms
which were developed during life. The state of unconsciousness which
resulted from the cerebral concussion, produced by the fall, passed directly
into that which resulted from the cerebral compression, produced by the
extravasated blood ; hence, the patient at no time after the accident recov-
ered his senses. Both cerebral hemispheres were simultaneously com-
pressed ; therefore hemiplegic symptoms did not appear, as they would
have done had only one of the hemispheres been subjected to the pressure.
This example is so highly instructive, as well as interesting, that no
apology for its presentation can be needed.

Case XI. Contusion and Laceration of the Brain by Contre-Coup ; Death;
Autopsy. — Private U., cavalry detachment, United States Military Academy,
West Point, was admitted to this post hospital December 23, 1870, at 9 o'clock,
P. M., in a state of unconsciousness, and bleeding profusely from the left ear,
having fallen down stairs upon his head while intoxicated. There was, however,
no wound or swelling discernible on the scalp to indicate the point of impact,
and the external examination revealed nothing. Pulse 70, full but compressible,
and intermitting twice per minute; respirations 16, heavy and stertorous, like

48 Li dell, Contusions of the Brain and of the Spinal Cord. [July

those of drunkenness; pupils dilated (somewhat), hut respondent to light. H<-
was extremely restless, and required two attendants to keep him in bed ; he mut-
tered incessantly and unintelligibly through the night. Shortly after admission
to the hospital, the aural hemorrhage subsided to an oozing, which continued as
long as life lasted. The blood was chiefly arterial ; no serum could be discerned.
To his head cold applications were made, and his extremities were kept warm by
hot bottles.

24th. Patient still unconscious ; pulse 54, full, compressible, and intermitting,
the same as last night ; pupils slightly but equally dilated, and responsive to
light; temperature 98°; respirations 1G, and their character unchanged; rest-
lessness continues ; lie is constantly attempting to get out of bed. and is restrained
only by the employment of much physical force by his attendants ; he mutters
incessantly. His bowels were moved by enema unconsciously. His bladder was
evacuated unconsciously twice during the day ; urine normal in colour and quan-
tity. He was unable to swallow ; beef-tea was administered by injection.

25th. No perceptible change ; bowels moved, and urine voided involuntarily ;
still muttering and restless. Upon being slapped quite smartly on his cheek with

the lingers, he uttered an expression of disgust in a single word , the only

evidence of consciousness which he exhibited after the accident. Beef-tea and
brandy, largely diluted, were injected every two hours, as he could not swallow.

26th. 6 A. M., pulse GG ; respirations 17 ; temperature 98°; restlessness con-
tinues: patient rolls unconsciously from side to side, and frequently attempts to get
out of bed. 12 M., pulse 50 ; respirations 1G ; temperature 100°. 4 P. M., no
change worthy of mention. At 8 P. M., reaction set in violently ; pulse 1 50 ; tem-
perature 105°; respirations variable, from 14 to 19. From this hour he sank
rapidly ; his pulse rose to 200. At 5 A. M. on the 27th (on the fourth day after
the accident) he died. The decubitus of this patient was either dorsal or left
lateral, but chiefly the latter. The jactitation was the most prominent symptom
throughout.

Autopsy. — Beneath the scalp an extensive extravasation of blood was found,
chiefly on the left side, but no clots. At the left parietal eminence there was a
slightly depressed fracture, with fissures extending into the petrous bone. At the
point of direct impact the outer table was driven into the diploe, and exhibited two
fissures, crossing at right angles, an inch and a half and an inch in length, respec-
tively. The inner table was very slightly depressed at the same point. Extending
from this depression to the auditory canal there was a broad fissure which passed
through the petrous bone. When the skullcap was removed, a blood-clot, nearly
circular, two and one-half inches in diameter by half an inch in thickness at the
centre, was found immediately under the depression, and lying between the bone
and the dura mater. Dark fluid blood mixed with serum, estimated at six
ounces, escaped from the opened skull.

Immediately under the right frontal protuberance, at a point diagonally oppo-
site the depressed fracture (the force of the blow having evidently been trans-
mitted from behind forward and obliquely toward the right), the surface of the
brain was found lacerated and contused by contre-coup, over a space and to a
depth nearly equal to the dimensions of the blood-clot above described. {Circular
No. 3, S. G O., August 17, 1871, p. 126.)

The contusion of the cerebral substance in this example had no direct
relationship with the fracture of the cranium. Each of these lesions, how-
ever, was simultaneously caused by the same violent application of force,
although they were developed on opposite sides of the head. Moreover,
this case presents one of the most remarkable instances of contusion of
the brain by contre-coup with which I am acquainted.

The symptoms of " shock" lasted a very long time, for the temperature
remained below the normal almost three days. The observation that
"jactitation was the most prominent symptom throughout" is worthy of

1883.] Lid ell, Contusions of the Brain and of the Spinal Cord. 49

being specially recalled to mind, as being one of the most important of all
the phenomena which result from contusion and laceration of the brain.

In the number of this Journal for July, 1866, page 74, Dr. John Ash-
hurst, Jr., reports a note-worthy case of contusion and laceration of the
brain by contre-coup, produced by falling from the third-story window of
a dwelling-house. The patient died three days afterward at the Episcopal
Hospital. "An autopsy was made five hours after death with the follow-
ing results : His scalp was infiltrated with blood, and, when raised, dis-
played a fracture involving the orbital plate of the frontal bone, with the
temporal and sphenoid bones on the left side. The membranes were con-
gested at the seat of fracture, and there was considerable laceration and
contusion of the brain at the base on the right side, directly opposite the
seat of fracture, and apparently produced by the contre-coup or counter-
stroke of the older writers."

We conclude as follows: (1) It is of some practical importance to
know that contusions of the brain by contre-coup are very frequently met
with in cases where the injury has been caused by falling on the head, as
the foregoing examples clearly attest, and several additional instances of
the same sort will be mentioned in the sequel. If I were to judge from
my own experience I should say that, in a large majority of the instances
where contusion of the brain is produced by falling on the head, it is
caused by the counter-stroke, and presents itself on the side of the head
opposite to that which receives the blow.

(2) In accounting for the energy of the counter-stroke in such cases it
should be remembered that the brain does not completely fill the cranial
cavity; for there is a considerable space surrounding it, embraced for the
most part in the meshes of the pia mater, which is constantly filled with
cerebro-spinal fluid. Indeed, the base of the brain rests upon and is sup-
ported by this fluid to such an extent that Mr. Hilton has quite properly
called it "the perfect water-bed of the brain." (Rest and Pain, p. 16,
Am. ed.)

(3) Cerebral abscesses sometimes form on the side of the head opposite
that which has been struck, in consequence of injury by contre-coup.
Thus, Bartholin saw a blow on the head followed by an abscess on the
other side ; and, when a blow has been received on the upper part of the
head, the abscess will sometimes be found near the base of the brain. In
a case of this sort reported by Pigray the abscess was very small, and did
not prove fatal until six months after the accident. When a cerebral
abscess arises from injury of the brain by contre-coup, it generally causes
some symptoms which should excite a suspicion of its presence. These
symptoms are fixed pain at the seat of injury by contre-coup, paralysis of
an arm or a leg, and even complete hemiplegia on the side of body oppo-
site the seat of fixed pain in the head, i. e., on the same side of the body
as the part of the head that received the blow, together with irregular

No. CLXXI July 1883. 4

50 Lidell, Contusions of the Brain and of the Spinal Cord. [July

shiverings and fever. The doctrines of cerebral localization may also
furnish important aid in determining the site of such an abscess. Should
the diagnosis of cerebral abscess by contre-coup be clear, the operation of
trephining and evacuating the abscess by puncture or aspiration (if prac-
ticable) would be demanded ; "and, in honour of the ancients, we may
cite the case related by Amatus, who applied the trepan to the part of the
head opposite to the wound, when he found that the symptoms were not
relieved by applying it on the side wounded, and that the patient suffered
from severe pain on the other side ; this second trepan proved very
apropos, for it allowed the escape of pus which had collected under the
skull. (Memoirs of the Royal Academy of Surgery of France, Syd. Soc.
translation, p. 21.) The patient made a good recovery.

But we must not overlook the terrible cases of cerebral contusion in
which, in consequence of the laceration of bloodvessels (in the pia mater)
having a considerable magnitude, blood is poured out with great rapidity,
as well as in great quantity, and death by compression of the brain speedily
ensues. In such cases the extravasated blood is found, on examination
post mortem, either (1) in the arachnoid cavity, or (2) in the subarach-
noid space, i. e., in the meshes of the pia mater and in the furrows of the
brain, as has already been imtimated on a previous page. I shall illus-
trate each of the varieties by a few examples of a typical character se-
lected from my note-book. But, inasmuch as these cases are utterly
irremediable, I shall offer but few comments concerning them. I should,
however, state at the outset that these cases are of very frequent occur-
rence ; were it otherwise, I would not take space to consider them.

Case XII. Cerebral Contusion by Cord re-Coup ; Insensibility ; Epi-
leptiform Convulsions ; Coma; Death; Autopsy; Profuse Hemorrhage
into the Arachnoid Cavity, etc. — Bernhart U., aged 45 years, a tailor,
said to have been grossly intemperate for years, injured his head by fall-
ing backward upon the pavement, about 10 P. M. November 4th. He
was picked up insensible, and carried home. There was a contused and
lacerated wound of the scalp, which bled freely. About midnight convul-
sions supervened, and continued until 7 o'clock A. M. on the 5th, when he
died comatose, having remained insensible from the beginning. The con-
vulsions were intermittent, the interval between them being about twenty
minutes. His friends, supposing him to be only grossly intoxicated, did
not bring a physician.

Autopsy by the writer (for the coroner) eight hours after death — Cad-
aver pale, stout, and fat. On the back part of his head, over the rear end
of the left cerebral hemisphere, was found a contused and lacerated wound
of the scalp, about one inch in length ; scalp itself congested. His skull
was thick and eburnized, but not injured. A considerable quantity of
bloody serum escaped from the cranial cavity while the skullcap was
being sawed off. In the arachnoid cavity, above and in front of the right
cerebral hemisphere, about three ounces of fluid and coagulated blood were
found ; this coagulum exhibited the greatest thickness upon the frontal
end of the hemisphere. In the meshes of the pia mater, underneath the
arachnoid, a considerable quantity of bloody serous effusion was found on

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 51

the whole convex surface of the right cerebral hemisphere. A larger
quantity of pale, limpid serum was found etfused beneath the arachnoid
investing the left cerebral hemisphere, which filled the sulci, distended
the pia mater, raised up the arachnoid itself, and gave it a pale, jelly-like
appearance. No blood or bloody serum was found on the left hemisphere.
The substance of the brain was remarkably firm in consistence throughout
and congested, but its colour was normal. The ventricles contained nearly
two ounces of bloody serum. It is probable that the chronically congested
state of the scalp, the eburnized condition of the skull, the indurated,
shrunken, and chronically congested state of the brain just described, had
resulted from the long-continued action of the alcohol with which his cir-
culating blood had been heavily and habitually charged for years. I was
informed that he had consumed a bottleful of gin every day for a long
time.

Case XIII. Cerebral Contusion by Contre-Coup caused by a fall ; In-
sensibility ; Coma; Death; Autopsy; much extravasated Blood found
in the Arachnoid Cavity, etc Margaret T., apparently middle-aged, in-
jured her head severely by falling backward thereon, September 2"2d, and
was picked up in an insensible condition. A few hours afterward she
died, with the symptoms of a fatal compression of the brain.

Autopsy by the writer (for the coroner). — Right pupil dilated ; left one
natural. While dissecting off the scalp, a large bruise was found on the
back part of the head, a little to the left of the median line, i. e., over the
posterior extremity of the left cerebral hemisphere. The skull was not
injured. On removing the skullcap and dura mater, a large quantity of
blood, both fluid and coagulated (more than four ounces), wras found on
the free surface of the arachnoid membrane, spread over the convexity of
the right cerebral hemisphere ;* but the layer of coagulum was thickest
over the anterior lobe (particularly at the anterior extremity thereof), and
it was thicker over the middle lobe than over the posterior one. The
source of this hemorrhage could not be found. No hemorrhage upon nor
within the left hemisphere, nor in any other part of the brain. The ven-
tricles were nearly empty. The substance of the brain appeared through-
out to be normal in colour and consistence. The organs of the thorax and
abdomen presented no abnormity worthy of mention in this connection.
There were no anatomical evidences of alcoholism.

In the last twTo examples the extravasation of blood was due to the
laceration of some important vessels of the pia mater, attended with cor-
responding rents in the arachnoid, which was caused by the bruising from
a counter-stroke of the part of the cerebral membranes from which the
hemorrhage occurred. In both alike the unfortunate subject received a
violent blow on the head at a point corresponding to the posterior ex-
tremity of the left cerebral hemisphere, the shock, impulse, or vibrations
arising from which were directly communicated to the contents of the
skull, although the skull itself was not broken, and were transmitted
obliquely through the centre of the brain, in a straight line, to the inner
surface of the right frontal bone, against which the anterior lobe of the
right cerebral hemisphere was violently projected by the transmitted* force
or vibrations, and in such a manner as to lacerate its small superficial
bloodvessels, together with the arachnoid membrane, at the point thereon
where the counter-blow from the right frontal bone reacted with the
greatest energy. Therefore, in both instances alike, the hemorrhage was
restricted to the space surrounding the right cerebral hemisphere, and the
flattened coagulum resulting therefrom was found to have its greatest

52 Lid ell, Contusions of the Brain and of the Spinal Cord. [July

thickness on the front part of the anterior lobe, at the place where the
bruising and laceration occurred, and from which the extra vasated blood
itself was poured out.

Case XIV. Extravasation {profuse) of Blood beneatlt the Visceral
Arachnoid Membrane, caused by Cerebral Contusion without Fracture ;
Sudden Death ; Autopsy. — Mrs. Mary M., aged 35, said to have been
badly beaten by her husband on the afternoon of March 12th, was found
lying dead upon the floor of her apartment in a house occupied by several
families at 6 o'clock P. M. on the second day. Her hair was dishevelled
and dress disordered. The precise time when death occurred is not known.
She had, however, probably been dead for more than an hour, as her body
was already cool when it was discovered. Her habits were temperate, and
she was nursing a young child.

Autopsy by the writer eighteen hours (about) after death — Rigor mortis
very slight. .Fresh bruises were found on the back of the left hand and
wrist ; also upon the face, and especially on the left eyelids. While dis-
secting off the scalp the marks of a severe contusion were found over the
right temporal muscle. The tissue of this muscle was infiltrated with
fresh blood to considerable extent. On removing the skullcap and dura
mater, and exposing the surface of the brain, a large quantity of extrava-
sated blood was found beneath the visceral arachnoid membrane in the
meshes of the pia mater. This sanguinolent effusion was spread out over
the left temporal region, the anterior portion of both cerebral hemispheres,
the right temporal region, and the base of the brain. It was more abun-
dant about the medulla oblongata and the cerebellum than elsewhere. It
was also more abundant in the left than in the right temporal region. The
blood lying in the furrows of the brain, in the fissure of Sylvius, and upon
the medulla oblongata was coagulated. The quantity of this sanguinolent
effusion, both fluid and coagulated, was estimated at more than half a pint.
The lateral ventricles contained a little bloody serum, and the right one also
a small coagulum. The substance of the brain seemed to be somewhat
softer, or less firm than natural, throughout its whole extent. The sub-
stance of the brain was not lacerated in any part. It also did not contain
any extravasated blood. The sanguinolent etfusion was found on the sur-
face, and in the right ventricle, but not elsewhere. The skull was not
fractured. It was carefully examined. The lungs, heart, liver, and spleen
were natural. The stomach contained six or eight ounces of partially
digested food. The organ itself was natural. The kidneys looked healthy.
But the muscular tissue generally appeared to be somewhat softened. As
already stated, she was giving suck to a young child at the time of her
death.

Case XV. Copious Extravasation of Blood beneath the Visceral
Arachnoid Membrane, caused by Cerebral Contusion without Fracture ;
Subject found Dead; Autopsy ; Heart Hypertropliied ; Lungs Congested ;

Liver and Kidney Granular : Spleen Enlarged, etc Wm. F., net. about

49, but looking considerably older, after being unwell about a week (he
had been rather feeble for a much longer period, but not confined to his
room at any time), was found sitting on a box in his room quite dead, on
the morning of March 16th. His face, or rather the left side of his head
and face, was covered with dried blood. The hair on the left side of his
head was matted together with dried blood, which had flowed from a
wound of the scalp. The authorities tried diligently but in vain to ascer-
tain how he had been injured.

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 53

Autopsy by the writer, March 17th, at nine o'clock A. M Cadaver

emaciated and jaundiced (light-yellow), and without post-mortem rigidity.
Recent bruises were found on the left arm, left shoulder, left side of the
neck, and the nose. On dissecting otf the scalp the marks of a severe
contusion 'were found on the left side of the head, above the left ear, and
over the origin of the temporal muscle. The texture of the scalp vjcis dis-
integrated, as it would be by a strong blow with a blunt instrument,
through a space rather more than three-fourths of an inch in diameter.
There were marks of several lighter bruises in the same locality, and the
tissue of the temporal muscle was infiltrated with fresh blood to consider-
able extent. On removing the skullcap and the dura mater, blood was
discovered to be extensively effused beneath the visceral arachnoid mem-
brane, in the left temporal region, at the base of the anterior lobes (both)
of the cerebrum, and on the anterior surface of the medulla oblongata.
This blood was coagulated, and in the fissure of Sylvius the clot was half
an inch in thickness. The substance of the brain was of firm consistence
in every part, and did not contain any extravasated blood. The lateral
ventricles, however, contained a small quantity of serum tinged with
blood. The skull was not broken.

The lungs exhibited some emphysema (vesicular), and were somewhat
congested with venous blood. In the apex of the right lung some deposits
of tubercular matter were found, which were undergoing the process of
repair. They were surrounded with a distinct membranous envelope or
capsule. They were also of the consistence of dry hard cheese, white in
colour, and softer at the centre than at the circumference. Some of them
were infiltrated to greater or less extent with pigmentum nigrum.

The heart was hypertrophied, and much larger than natural. The
mitral and one of the aortic valves were somewhat thickened. Both car-
diac chambers contained clots.

The liver was much enlarged and flattened in shape. It was also
granular in appearance and feel externally. On section the structure
was found to be coarsely granular. The granules varied in size, but the
abnormity was uniform in every part of the organ. The hepatic tissue
was brittle, and weaker than natural. The quantity of blood contained
in the organ was smaller than natural.

The spleen was much enlarged. It measured six inches in length, five
inches in breadth, and three inches in thickness. It weighed one pound
and six ounces. Its consistence was normal. On section it presented a
reddish-brown colour, with numerous white or yellowish-white spots, of
the size of a pin's head, thickly and uniformly scattered over the cut sur-
face. These spots were the divided trabecular of the organ.

The kidneys also were much enlarged. The cortical portion of each
organ contained an abundant quantity of a yellowish-white substance,
having a firm consistence. In the left kidney this substance was infil-
trated uniformly throughout the cortical portion. In the right kidney,
in addition to said infiltration of the cortical portion, two yellowish-white
.spots were found, one near each end of the organ, which had been pro-
duced by a filling up of two pyramids with a semi-cartilaginous substance
infiltrated into the tubular structure.

The stomach contained a few ounces of fluid tinged with bile. The
organ itself was natural.

Beneath the contusion on the left side of the neck, mentioned above, the
connective and even the muscular tissues were found to be infiltrated with
blood to considerable extent.

54 Lid ell, Contusions of the Brain and of the Spinal Cord. [July

The lesions presented by the liver, spleen, and kidneys in this case, but
especially those of the last-named organ, are very interesting, and, there-
fore, I have not " cut out" the description of them, although they probably
had little (if anything) to do with the subarachnoid extravasation of blood
which resulted from the traumatism.

Case XVI. Contusion of the Pons Varolii and Crura Cerebri, caused
by falling on the Head; Death: Autopsy: much Blood also found in the
Arachnoid Cavity. — Mrs. Catharine T., aged 3G, died rather suddenly on
December 19th, from an injury of the head, caused (most probably) by
falling thereon. Her circumstances in life were comfortable, and she had
borne several children. Nevertheless, her relatives informed me that for
eight years she had been a toper, and for three years a drunkard. Her
death was preceded by coma and stertorous breathing.

Necroscopy by the writer, December 20th, 1 P. M. — Cadaver fat, and
presented a jaundiced hue (yellowish). There were marks of bruises
found on the forehead and hairy scalp, on the right side of the face and
lower jaw, on the breast, arms, and legs. The largest, however, was on
the lower jaw. Skull not broken. On removing the skullcap and dura
mater, about four ounces of coagulated blood were found in the left arach-
noid cavity, lying upon the anterior and middle lobes of the left cerebral
hemisphere, which had correspondingly depressed and flattened the cere-
bral convolutions. The ventricles held a little pale fluid. The central
portions of the pons Varolii and crura cerebri were softer than normal,
and contained some extravasated blood. The softened brain-substance
was stained with blood, it being dark-red in the centre, next to that red-
dish-yellow, then yellow, and, finally, yellowish-white in colour at the
circumference. The other parts of the brain were all quite firm in con-
sistence, and normal in colour. The source of the meningeal hemorrhage
could not be determined. There was no appreciable laceration of the
meninges. The contusion of the brain-substance was apparently restricted
to the pons and crura cerebri, as above described. Externally, these
structures presented a perfectly normal appearance.

Inasmuch as this patient's history was that of confirmed alcoholism, it
may be both useful and interesting to describe the morbid appearances
which were presented by the other internal organs. They were such as
usually arise from chronic alcoholism.

The lungs were congested and emphysematous. The left one con-
tained a few small tubercles. There were no pleuritic adhesions. On
the exterior of the pericardial sac an abundant quantity of adipose tissue
was found.

The heart was large and fatty externally. On the right ventricle the
lamina of adipose tissue had encroached considerably upon the muscular
structure of the organ. In some spots it extended almost through the
ventricular wall to the endocardium. Under the microscope some mus-
cular tissue taken from the right ventricle was seen to present fibres that
were perfectly healthy with adipose tissue of the usual kind, i. e., consist-
ing of little sacs filled with oil, dipping down between them. The mus-
cular tissue of the left ventricle presented a natural appearance under the
microscope.

The liver was enlarged to about twice its normal size and fatty. It had
a lemon-yellow colour that was nearly uniform in every part of the organ.
The edges of the right lobe especially were well rounded off. The hepatic
tissue was hard in feel and brittle in consistence.

1883.] Lidell, Contusions of the Brain and of the Spinal Cord. 55

The spleen was softened and darker in colour than natural, but pre-
sented no other abnormity.

The kidneys were large in size, firm in consistence, and congested ; but
portions of their cortical substance (spots) presented a colour that was
paler than natural, and paler than the rest of the cortical structure. Under
the microscope these whitened parts of the cortical substance were seen to
contain decidedly more fat globules than the un whitened parts ; but even
in the last mentioned there was more than the normal quantity of fat
globules. The slide prepared from the whitened parts exhibited the fat
vesicles aggregated into patches in some portions of the field, while they
were scattered and isolated in other portions.

The mucous membrane of the stomach was mamelonated, thickened,
and softened. It exhibited punctiform injection along the lesser curva-
ture, but elsewhere its colour was uniformly pale, i. e., white, slightly
tinged with a yellowish ashy hue. The gastric mucous membrane bore
no inconsiderable resemblance to rotten leather, having a dirty yellowish-
white colour.

The uterus exhibited old fibrous bands of adhesion upon its exterior,
the results of a circumscribed inflammation of the peritoneum, which had
occurred long previously. One Fallopian tube was dropsical; it was bent
downward and fastened to the womb by old adhesions ; it was also con-
stricted at several points, and on that account presented a lobulated or
bead-like appearance. In the ovaries some of the Graafian vesicles were
dilated into cysts, but none of them had reached any considerable size.

The bladder was distended with urine, which had accumulated after
coma supervened.

The lesions which are most characteristic of chronic alcoholism were
well shown in this case. They are briefly as follows : A mamelonated,
thickened, softened, dirty yellowish-white, or rotten leather-like condition
of the gastric mucous membrane, with patches of punctiform congestion ;
an enlarged, fatty, and flabby heart ; a greatly enlarged and fatty liver,
with inflammatory thickening of Glisson's capsule ; enlarged and fatty
kidneys; a disordered spleen ; and an excessive deposit of fat in the gene-
ral connective tissue, especially about the abdomen and thorax.

But the most important features of this example, for our present purpose,
were the contusions of the pons Varolii and crura cerebri. There are but
few instances of this form of injury on record. Mr. Prescott Hewett states
(Holmes's System of Surgery, vol. ii. p. 312) that only five cases belong-
ing to this category were met with at St. George's Hospital, within the
space of sixteen years. In an example mentioned by M. Boinet (Archives
Gen. de Medecine, 1857, p. 50), the centre of the pons was bruised, and
this was the only injury of the brain-substance which was discerned. In
another example mentioned by M. Fano (Reck, sur la Cont. du Cerv., obs.
xii. p. 25), the parenchyma of the pons was studded with a number of
small sanguinolent extravasations, about the size of a split pea, while the
anterior lobes of the cerebrum were extensively bruised and lacerated,
although the cranium was not fractured. The case related above, how-
ever, shows that the centre of the pons Varolii, as well as that of each

56 Lidell, Contusions of the Brain and of the Spinal Cord. [July

crus cerebri, may be broken down by a traumatic extravasation of blood,
while the exterior of the injured organ presents no morbid appearance
whatever. Obviously, such a lesion might readily elude detection, unless
particularly sought for. Obviously, too, this example of brain contusion
should be permanently recorded, because of its extreme rarity.

Contusions of the Spinal Cord.

Case XVII. Contusion of the Spinal Cord, caused by a blow on the
back from a falling tree ; Paraplegia : Death six dags after the acci-
dent; Autopsy; Linear Fracture of the first and, second Dorsal Verte-
brae (?'. e., fracture loithout displacement) also present. — Private John II .
Rhodes, Co. A, 6th Pennsylvania Cavalry, aged 22, and always healthy,
was brought to the Depot Field Hospital at City Point from the front,
in a paraplegic condition, December 14, 1864, where I saw him on the
following day, and inquired into his case with much care. His mind was
not at all affected ; he said his disorder had resulted from an injury. On
Sunday, December 11, while lying on the ground face downwards (his
troop was posted in the woods at the time) a tree fell, and some branches
belonging to its top struck him violently across the back and shoulders ;
he was instantly deprived of the use of his lower extremities and the
lower part of his body. On examination I found that there was com-
plete paralysis, both sensory and motor, of all the parts below the umbili-
cus. The detrusor urime muscle being paralyzed catheterization was
required twice daily ; urine ammoniacal, and more abundant (in quantity)
than normal. No motion of the bowels since the accident (four days
before). Reflex motor action in the lower extremities was entirely sus-
pended ; for, on tickling the soles of his feet, and pulling the hairs of his
legs, thighs, and groins, I failed to excite any motor reflex, as well as any
sensibility ; both lower extremities were alike in these respects. Above
the umbilicus sensibility shortly began to be discerned, at first faintly,
but with increasing distinctness on proceeding upward, until it became
normal on the upper part of the thorax. The respiration was abdominal
(i. e., diaphragmatic), and superior thoracic (i. e., superior intercostal).
He had good use of the upper extremities (both), and made no complaint
about them whatever. He was now carefully turned over upon his right
side, so as to permit an examination of his back. It was then discovered
that a consistent stool had just been passed spontaneously and uncon-
sciously by him in bed. There was no appearance of contusion nor ecchy-
mosis on Kis back and shoulders ; there was no deformity of the spinal
column manifested to the eye. On careful exploration of the vertebral
spines with the fingers no abnormal mobility of these processes was
anywhere present. It was thought, however, that the extremity of the
fifth dorsal spine was less prominent than the extremity of the fourth, and
that it deviated slightly toward the left (about two lines). At the upper
part of the dorsal region there was tenderness (moderate) under pressure
upon the vertebras (first two or three dorsal) discerned. He did not com-
plain of feeling hurt in any part while being turned over in bed ; did not
complain of distress in any part of his body. He had considerable cough,
with expectoration ; sputa unstained ; his face had a dusky hue (not
deep). He said his cough was better than it had been ; and he thought
he had taken cold ; no difficulty in swallowing solids as well as liquids ;
no priapism. The patient, grew worse ; his breathing became more and

1883.] Lid ell, Contusions of the Brain and of the Spinal Cord. 57

more difficult ; and on the 17th he died from failure of the respiratory-
function, six days after the casualty occurred.

Autopsy, Dec. IS. — Rigor mortis strong; body muscular and well de-
veloped; no deformity of spinal column discernible on external examination.
While dissecting off the dorsal muscles in order to expose the spinal
column a small quantity of extra vasated blood was found among the
fibres of these muscles in the neighbourhood of the three upper dorsal
vertebrae, but there was no cutaneous ecchymosis. There was a fracture
of the first and second dorsal vertebra?, with but little, if any, displace-
ment of the fragments. It passed through the body of the second and the
laminae of the first. The anterior vertebral ligament was slightly lacer-
ated opposite the fracture. The posterior vertebral ligament was not
torn ; but it was detached (loosened) to some extent around the fracture.
External to the theca vertebralis, between it and the bone, some coagu-
lated blood was found opposite the fracture. It constituted a thin, narrow
strip, about two inches in length by one-fourth of an inch in breadth ; it
extended along the left side of the theca, and exerted no pressure what-
ever on the cord. Within the theca no blood nor bloody fluid was found.
Externally the spinal cord presented a normal appearance, i.e., its exte-
rior was not discoloured, nor lacerated, nor notched by compression. On
making a longitudinal section, however, the gray substance within the
cord was found to present an ecchymosed and bruised appearance oppo-
site the site of the vertebral fracture ; the gray substance here was dark-
brown in colour, in consequence of its infiltration with blood which had
escaped from the ruptured capillaries ; and it was also pulpified by the
force of the contusion. This pathological condition of the gray matter
was restricted to the locality of the vertebral fracture. It was also sym-
metrical in both lateral halves of the cord. As before stated, the exterior
of the cord presented no abnormal appearance whatever to the eye in
even this locality ; no inflammation of the membranes or substance of
the spinal cord. The spinal column exhibited slight lateral curvature, the
convexity being on the right side.

Thorax. No ribs were broken ; no pleuritic adhesions ; both lungs
alike contained more than the normal quantity of blood from passive
hyperasmia, but otherwise were sound. The pericardium contained about
one ounce of serum stained with blood (post-mortem) ; heart normal ;
abdominal organs normal.

The part of the spinal cord which is most apt to suffer from contusions
is the gray substance of its interior ; and, therefore, it not unfrequently
happens that the organ is badly damaged in this way without exhibiting
externally any appearance of injury, as occurred in the case just related.
Furthermore, this patient suffered from concussion as well as from contu-
sion of the spinal cord. He consequently exhibited reflex motor paralysis,
as well as total loss of sensation and voluntary motion in all those parts
of his body which were supplied by spinal nerves that issued from the
cord below the injured spot. The extravasation of blood into the gray
substance of the cord suppressed its functions as a conductor of impres-
sions to and from the sensorium commune, while the concussion of the
cord suppressed its functions as a series of independent nervous centres

58 Lid ell, Contusions of the Brain and of the Spinal Cord. [July

arranged one above another, and in this way produced reflex motor
paralysis of wide extent.

But the brain and the spinal cord are sometimes, perhaps not [infre-
quently, affected simultaneously by concussion, as, for example, they were
in the following instance, which was reported by Mr. Savory. In such
cases the nature of the vulnerating force is always such that the brain as
well as the spinal cord, i. <?., the whole cerebro-spinal axis, is subjected to
its operation at the same moment.

Mr. Savory narrates (St. Bartholomew' s Hospital Reports, vol. v. p.
459) the case of a man who was injured by falling on his head from a
railway van. For some minutes he was stunned, but this soon passed off
When admitted into the hospital there was found to be complete loss of
motion and sensation in all of his extremities, both lower and upper, and
in his trunk nearly as high as the clavicles. His respiration was entirely
diaphragmatic, and the walls of his chest sank inward at each inspiratory
effort. No reflex action could be excited in the lower extremities, nor
elsewhere. His pupils were moderately and equally dilated, but sluggish ;
partial priapism was present. In about thirty hours he died.

Autopsy No fracture nor displacement of any part of the skull or

spinal column was found, and there was no extravasation of blood nor
material congestion exhibited on the surface of the brain or that of the
spinal cord at any part thereof. But a longitudinal section of the cord
disclosed, opposite the fourth cervical vertebra, a clot of blood, which was
extravasated throughout its substance, to the extent of about half an inch.
The limits of this extravasation were well defined. Nothing wrong could
be detected in the adjacent nor in any other part of the cord. (New
Sydenham Soc. Retrospect, 1869-70, p. 248.)

Well-marked concussion of the brain was produced in this man's case
by falling on the head; but the symptoms arising therefrom soon passed
away. In about thirty hours, however, death resulted from another
cause ; and the autopsy showed that no cerebral hemorrhage, nor cerebral
congestion, nor any other abnormity of the brain which could be discerned
was present. No doubt, therefore, exists that concussion of the brain,
per se, is not attended with the occurrence of any structural lesion which
is recognizable by the anatomist after death, at the present time.

Well-marked concussion of the spinal cord was likewise produced by
the fall in this man's case ; but the symptoms arising therefrom did not
pass away. There persistently remained complete motor and sensory
paralysis of nearly the whole body excepting the head and neck, i. e., of
all those parts which are supplied with nerves that issue from the spinal
cord below a point opposite the fourth cervical vertebra. Not only that,
but there likewise remained almost complete absence of any reflex action;
even the pupils were dilated and sluggish. In fact, the functions of the
spinal cord were so strongly invaded by the injuries which it had sus-

1883.] Li dell, Contusions of the Brain and of the Spinal Cord. 59

tained that death ensued through the lungs, i. e., by suffocation resulting
from suspension of the respiratory movements, in about thirty hours, as
already stated. At the autopsy, blood in considerably quantity was found
extravasated in the interior of the spinal cord, i. <?., in its gray matter, at
a point opposite the fourth cervical vertebra. Here, there is presented to
us a case in which the two chief functions of the spinal cord, namely, that
of conducting impressions to and from the brain on the one hand, and
those peculiar offices which pertain to the cord as a series of independent,
although correlated nervous centres, on the other, were simultaneously
interrupted ; for there was not only complete loss of sensation and volun-
tary motion, but nearly complete loss of reflex nervous action also. It is
clear that while the loss of the conducting function of the cord can be
satisfactorily accounted for by the visible effects of the injury, i. e., the
extravasation of blood, which was found in the rachidian substance at the
autopsy, opposite the fourth cervical vertebra, the loss of its reflex func-
tions cannot be accounted for in this manner. The suppression or impair-
ment of the qualities of the spinal cord, as a series of nervous centres
arranged one above another, must have been due to the concussion to
which the rachidian substance in general was subjected by the fall; which,
however, produced no effect upon the rachidian substance which was visi-
ble after death. No doubt, therefore, exists that concussion of the spinal
cord, per se, is not attended with any change in structure or appearance
which is at present recognizable by the anatomist after death, and that the
rachidian and cerebral substance are alike free from any effects of concus-
sions that are visible on examination post mortem.

But contusion of the spinal cord, at a point opposite the fourth cervical
vertebra, appears to have been produced by the form of injury which this
man sustained, as well as cerebro-spinal concussion of a general character;
for the gray substance of the cord was found infiltrated with clotted blood
at that point to the extent of about half an inch, in such a manner as to
present morbid appearances closely resembling those which have been
observed in undoubted examples of rachidian contusion. Moreover, it is
by no means improbable that this man's fall was attended with a violent
flexure of his neck, at its middle part, of an abrupt or angular character,
and with a correspondingly short bending of the spinal cord at the same
point, which, together with the sudden shock or commotion of the rachi-
dian substance that resulted from the fall itself, burst open some capillaries
within the bent part of the cord, and caused the sanguinolent infiltration
of the rachidian substance above described. Thus, we find that in this
instance concussion of the brain and spinal cord was complicated with
contusion of the latter, and that death occurred in considerably less than
one and a half days.

Contusions of the spinal cord not unfrequently occur. They are often
met with in cases of vertebral fracture, and in cases of vertebral disloca-

60 Lidell, Contusions of the Brain and of the Spinal Cord. [July

tion. In such cases it very often happens that the spinal dura mater
(theca) is not torn ; and, not unfrequently, on laying it open, and finding
the spinal pia mater entire and without ecchymosis, as well as the exterior
of the cord free from any morbid appearance whatever, one might imagine
the cord itself to be quite uninjured, while, at the same time, the gray
substance of its interior is extensively disorganized and infiltrated with
dark-coloured blood, in consequence of the bruising to which the cord has
been subjected. Obviously these striking lesions are exposed to view only
by incising the cord through and through. Mr. Hutchinson, in a clinical
lecture (London Hospital Reports, vol. in.), has mentioned a case in which
the cord-substance was reddened internally by extra vasated blood, and
likewise broken into a diffluent pulp for nearly an inch and a half. He
also exhibited a drawing of the same ; yet, in this instance, the pia mater
was entire, and without ecchymosis.

But something should now be said concerning the prognosis and treat-
ment of concussions complicated with contusions of the spinal cord. In
such examples of these injuries as those presented above, examples
wherein the rachidian concussion is very severe and the contusion (which
is also severe) wounds the cervical part or the beginning of the dorsal
part of the cord, the prognosis is always very bad ; for the patient is ex-
ceedingly liable to perish before reparation of the bruised cord-substance
can be effected, in consequence of suffocation slowly produced by stagnation
of venous blood in the lungs, due to the respiratory movements — the act of
breathing — being not properly nor adequately performed, which necessarily
ensues when the conducting functions of the cord are suppressed in the
cervical region, and all the respiratory muscles are paralyzed excepting
the diaphragm. When, however, the contusion is seated in any portion
of the spinal cord whereof the constituent filaments and nerve-cells do not
exert any control over the movements of the muscles employed in the act
of breathing, for instance, in the middle and lower part of the dorsal, as
well as in the lumbar region, reparation and recovery may doubtless be
effected; and the prognosis in such instances is therefore much less un-
favourable. At any rate, it is scarcely more unreasonable to expect to
obtain the cure of such cases by treating them judiciously, than it is to
expect to obtain the cure of so-called cases of infantile spinal paralysis,
wherein the rachidian lesion consists of disorganization of the gray matter
in the anterior cornua, and is therefore closely analogous to the rachidian
lesion which exists in those instances of contusion of the cord-substance
where the bruising and the ecchymosis are restricted to the gray matter
thereof, which instances probably constitute a large majority of the injuries
in question. Moreover, it is now well known that cases of infantile spinal
paralysis are not unfrequently cured without much difficulty by appropriate
treatment.

In conducting the treatment of contusion of the spinal cord-substance.

1883.] Lid ell, Contusions of the Brain and of the Spinal Cord. 61

the indications to be fulfilled are : (1) to promote absorption of the extra-
vasated blood ; (2) to lessen the rachidian hyperemia, both arterial and
venous, which is always liable to supervene in such cases ; and (3) to
prevent the development of myelitis, especially the suppurative and dif-
fuse or ascending forms thereof, as well as the development of spinal men-
ingitis. A remedial measure of transcendent importance in such cases is
quietude or rest of the injured part, as nearly absolute as possible. If the
rachidian contusion be caused by luxation of the vertebra?, or by fracture
with displacement of these bones, the displaced vertebras should always be
restored to the normal position, i. e., reduced, at the outset, either by means
of the patient's posture in bed, which sometimes suffices, or by means of
extension, counter-extension, and coaptation applied with the help of com-
petent assistants, in order that the wounded parts may be restored to those
surgical relationships which are most favourable to recovery. Indeed, the
statistics collected by Professor John Ashhurst, Jr. (Injuries of the Spine,
with an analysis of nearly four hundred cases, p. 66), very clearly show
" that the proportion of deaths has been almost three times larger when
general treatment has been exclusively used than when extension (com-
bined, of course, with rotation and pressure as required) has been em-
ployed." Should the vertebral displacement exhibit a tendency to return,
it must be overcome either by posturing (sometimes the placing of the
patient in a prone position in bed will do it), or by making continuous
extension and counter-extension by means of weights suspended at each
end of the bed with cords passing upward over pulleys and attached to
broad strips of adhesive plaster, which are fastened to the patient above
as well as below the seat of vertebral injury. Not unfrequently, how-
ever, the counter-extension can be successfully made by simply elevating
the foot of the patient's bed upon blocks of wood placed underneath the
legs thereof for that purpose. In such a case, the extension would be
made by a weight of twelve or fourteen pounds suspended at the foot of
the bed, in the manner indicated above.

"When continuous extension by means of weights is unnecessary, the
prone position is generally preferable to the supine, unless it greatly dis-
comforts the patient ; for it readily permits the application to the back of
leeches or cups, of ice-bag or ice-poultices, and of blisters or the hot iron,
whenever needed. At the same time, the back being the highest- instead
of the lowest part of the body, the tendency to hypostatic congestion of
the rachidian veins is much diminished by the prone posture of the patient,
and the tendency to myelitis and spinal meningitis is also correspondingly
lessened thereby.

The absorption of extravasated blood and serum may be considerably
promoted by administering (per orem) potassium iodide in doses of ten
grains three times a day. Rachidian congestion, venous as well as arterial,
can be considerably lessened by administering in the same way the fluid

62 Lidell, Contusions of the Brain and of the Spinal Cord. [July

extract of ergot in full doses. Strychnia should never be prescribed for
such patients, for it always harms them. Should, however, myelitis or
spinal meningitis unhappily supervene, it must be combated, at the outset,
by leeching or cupping the back over the seat of injury, followed by cold
applications; later, by blisters or hot iron, the latter generally proving
more useful. Internally, potassium iodide and ergot should be given in
large doses, as well as saline purgatives, and opium with sufficient freedom
to subdue all pain. Should the patient be unable to micturate at will,
catheterization must be performed at least twice a day. The diet must be
nourishing and easily digestible. Cleanliness of the genitalia and buttocks
must be continuously enforced, and great pains taken to prevent the de-
velopment of bed-sores.

Brief mention should also be made of the less severe instances of con-
cussion complicated with contusion of the spinal cord. For example :
A. man falls with considerable violence, his back striking upon the hard
ground. He immediately perceives a peculiar sensation of " pins and
needles" in his hands, feet, and legs, especially in the last two. He gets
up ; but, having done so, he finds that the motor power and sensibility of
his lower extremities are considerably lessened. Nevertheless, he man-
ages to ride home, and at once goes to bed, hoping that he will be better
on the morrow. But, after passing a restless night, he finds in the morn-
ing that the numbness and weakness of his lower limbs have not dimin-
ished ; furthermore, he is unable to get up because, as he says, he is in
pain all over; he feels sore and stiff just as he would if he had been
bruised all over, so that .it is painful for him to attempt to stir his limbs,
or to try to make any movement whatever. He also finds himself unable
to urinate.

What has happened to this man ? He has not caught cold ; nor has he
rheumatism ; nor has he been strained nor bruised externally. He has
received no strain nor bruise in the parts where the pain and soreness are
perceived. This state of general hyperesthesia which he experiences,
together with the diminution of motor power and sensibility in the lower
extremities, as well as the inability to urinate, all result from a structural
disturbance which the spinal cord sustained in consequence of the blow on
the back ; in other words, there occurred in this case concussion compli-
cated with slight contusion of the rachidian substance, which were followed
by active hyperemia of the same. The treatment should consist in the
application of numerous dry cups to the back on each side of the spinous
process, with extract, belladonnas, gr. J, administered four times a day,
catheterization twice daily, and rest in bed. Under this plan of treatment
complete recovery will soon be obtained.

But should the patient discard the advice in respect to remaining quietly
at rest in bed until the spinal symptoms have entirely passed away, he will
be very liable to acquire for himself suppurative myelitis and incurable

1883.] Atkinson, Woods, Iodine in Malarial Fevers. 63

paraplegia, as happened in the case mentioned by Mr. Hilton {Rest and
Pain, p. 33), of a man who had a fall upon his back at Epsom, from the
giving way of a scaffold. He immediately experienced the sensation of
" pins and needles" in his legs. Being a most energetic man, he arose
and ran six miles. He had been told, when a boy, that if he ever had an
accident of this kind he should run off its effects as soon as possible. In
a very short time, however, unequivocal spinal-marrow symptoms ensued,
which resulted in complete and irremediable paraplegia.

Finally, it should be stated in regard to contusions of the brain that
their symptoms have been described with sufficient copiousness in connec-
tion with the various examples which have been presented above ; also,
that the principal indications for their treatment are, (1) to prevent con-
secutive encephalitis, (2) to control such inflammation by remedial meas-
ures of sufficient energy should it unhappily supervene, and (3) to draw
off' the products of such inflammation {e.g., purulent matter, etc.) by tre-
phining the skull, and puncturing the cerebral membranous and cerebral
substance whenever they cause paralysis on the opposite side of the body
by compressing the cerebral substance, whether coma be likewise present
or not, for a cerebral abscess never spontaneously gets well.

17 Clinton Place, April, 1883.

Article III.

A Demonstration of the Feeble Influence of Iodine over Malarial
Fevers, based upon an Analysis of 76 cases of Intermittent and
Remittent Fevers treated with the Agent. By I. E. Atkinson,
M.D., Prof, of Pathology in University of Maryland, and Hiram Woods,
M.D., House Physician of Bay Yiew Asylum, Baltimore.

There have recently appeared numerous reports from medical men
in various parts of the world, reciting the virtues of iodine in the treat-
ment of malarial fevers. It is true that these do not all agree as to the
exact degree of reliance that may be placed in this agenj", as an antiperiodic.
There are, however, those who claim for it an efficacy not less than that
of the preparations of Peruvian bark, as far as the immediate control ot
the attack. is concerned; even greater than that of these agents in prevent-
ing its recurrence. Such was the experience of Dr. Grinnell, who treated
140 cases of malarial fever at the Wichita agency, Indian Territory
{Braithwaite's Retrospect, vol. 83), as well as that of Dr. W. M. Ander-
son {Proceedings of Med. Soc. of Kings County, 1879-80), who treated
at the South Brooklyn Dispensary, over 200 cases, of whom " a large
percentage returned .... enough to show, with private patients,

Atkinson, Woods, Iodine in Malarial Fevers,

[July

that the results were not merely post but propter hoc.'" Dr. R. B, Mori-
son reports highly gratifying results from the administration of 15-minim
doses of tincture of iodine, in 250 malarial cases treated during 1881. Of
the whole number, 150 were not heard from after the first visit, but of
the 100 who returned once, twice, or oftener, 84 were on record as cured,
2 as not cured, and 12 as not cured either with iodine or' cinchonidia.
Dr. Morison was so favourably impressed with the action of iodine in the
treatment of acute malarial diseases, that it was employed to the exclu-
sion of other remedies in his service in the out-patient department of the
University of Maryland, where his cases were treated {Maryland Med.
Journ., vol. 8, No. 20, p. 461).

Similar experience appears to have been acquired by Sircar [Indian
Med. Gaz.),. Gibbons {Pacific Med. and Surg. Journal, Sept. 1880),
Bell {Med. and Surg. Reporter, Phila. 1881, xlv.) (in chronic malarial
poisoning), Geoghan {Albany Medical Annals, 1880, iii.), who success-
fully treated 41 out of 43 cases of intermittent fever, Kemper {Amer.
Practitioner, xviii. 1878), Wadsworth {N. Y. Med. Journ., 1879, p.
493), and others. Willibrand (Virchow's Archiv, xlvii. p. 243) declares
that in iodine we possess a specific remedy for malarial diseases equal to
cinchona. Stille and Maisch extol the anti-malarial virtues of iodine,
and Bartholow (in the 4th edition of his Mat. Med., 1882, p. 222-223),
pronounces in its favour, relying, however, it would seem, more upon the
testimony of others than upon his own experience.

It must be confessed, however, that the results of the writers quoted do
not entirely agree. Here we find an assertion that it is in chronic
malarial poisoning that iodine does its work most effectually ; there, that
its value in this variety is nothing; in another article we find that the
drug is recommended to render permanent the cure that quinine has
begun ; in still another, that it is given in combination with quinine,
arsenic, etc. On the other hand, we find that anti-periodic properties
are denied to iodine by some. Thus, Fridenburg (Mt. Sinai Hospital
Reports, JV. Y. Med. Journ., 1880, xxxi. p. 50) obtained no good results
from its use ; and Bannergee in the Calcutta Med. Gaz., Jan. 1882,
relates a very interesting experience with iodine in the treatment of
malarial complaints. In 1878, Bannergee tried it in 7 cases with but a
single successful result. In 1879, he used iodine in 500 cases with very
satisfactory results (90 per cent, of cures). In 1880, he used it again in
nearly 160 cases, but without as great success. He now recognized that
many of these fevers were of an ephemeral character, and tended to limit
themselves, and arrived at the conclusion that about 20 per cent, of cases
are cured spontaneously either on the 3d, 4th, or 5th day, or sometimes
even on the 7th or 8th day. "He concludes that iodine is much inferior
in the treatment of these maladies to quinine.

Attracted by the testimony in its favour, and with the desire to defi-

1883.] Atkinson, Woods , Iodine in Malarial Fevers.

nitely ascertain the powers of iodine as an anti-malarial remedy, in view
of the ease of its administration, and of its comparatively small commer-
cial value, we availed ourselves of the opportunity of treating malarial
fevers, afforded at Bayview Asylum, Baltimore, during the late summer
and autumn of the past year (1882). We were the more impelled to test
the merits of the remedy, upon the one hand, on account of the very
unsatisfactory character of the evidence in its support, relating either to
dispensary practice or to general results, and, upon the other hand, be-
cause of the exceptionally favourable opportunities at our command of
observing a large number of cases of malarial fever throughout their
course, and of closely studying the effects of treatment. Our cases came
under observation during July, August, September, and October, and
were largely composed of foreign labourers who had contracted their
fevers while employed in fruit and vegetable canning establishments in
highly malarious sections of the neighbouring country. They number 76
cases of intermittent and remittent fevers, and their appended histories,
with the carefully recorded reports of the effects of treatment, clearly
demonstrate the very feeble influence of iodine over malarial diseases ;
at least over the acute forms, for with the treatment of chronic malarial
poisoning with iodine we have had but limited experience.

As stated, we treated in all 76 cases of malarial fever with the tincture
of iodine. The doses given varied with the demands of each case.
Usually, the dose was thirty drops (15 n^) of the officinal tincture of
iodine four times daily. Our plan was to give the iodine in this dose
steadily for five days, and if, at the end of that period, a cure had not
been effected, to substitute the sulphate of cinchonidia. We have pre-
ferred to classify and analyze our cases, rather than to report the full
history of each case as recorded, in order to avoid a tiresome and unin-
teresting lengthening of our article.

Of our 76 cases, we record only 16 as cured by iodine. An analysis
of these 16 cases, however, will show that recovery can by no means in
all of them, with certainty, be ascribed to the remedy. For, apart from
the well-known tendency of sufferers from chronic malarial poisoning
to develop irregular paroxysms' of ague, it is a matter of some doubt
whether one or two of them had malarial fever at all. It is evident
that uncertainty may well exist where one paroxysm of fever is reported
to have occurred, while there will be but little difficulty in definitely
determining the nature of cases whose symptoms afford repeated oppor-
tunities for recognition. The cases referred to belong to the early period
of our observations, and, though lacking the definiteness so desirable in
scientific research, we have concluded to report them for what they are
worth. In five only of our sixteen "cures" was the attack stopped at
once. These were Cases III., IX., XV., XLIV., and L. of our records.
Case III. reported irregular attacks of ague for more than two years.
No. CLXXL— July 1883. 5

Atkinson, Woods, Iodine in Malarial Fevers.

[July

She had also chronic Bright's disease. Case IX. had chronic malarial
poisoning, and claimed to have had " dumb ague" for two weeks. One
of the house physicians observed her with a single high temperature. She
was given twenty-five drops of tincture of iodine thrice daily for several
days, and had no return of the paroxysms. Case XV. gave a history of
two tertian chills. Twenty-five drops of the tincture were given thrice
daily. By the time of the next expected chill he had taken three doses
of the remedy. These were not sufficient to prevent it. His temperature
reached 102° F., but after this he had no more fever. Case XLIV. was
a half-starved individual who had been treated two weeks previously for
tertian fever with quinine. After admission he had one attack, with a
temperature of 100°, at the regular time. Thirty drops of the tincture
were given thrice daily, and he had no return of the ague. Case L. had
a single chill after admission, and was given the iodine immediately. He
had no subsequent paroxysm. It will be observed that of these, Cases
III. and IX. were subjects of chronic malarial intoxication, and that the
single chill observed in each. may have been one of its manifestations.

Four more of these sixteen cures occurred after from two to three days'
treatment. They were Cases II., VII., XXXI., and XLVIII. An ele-
ment of doubt also accompanies them. One (Case II.), a woman, asked
admission to the hospital ward on account of a chill which she claimed to
have had. This was denied her, and she was ordered to take fifteen
drops of the tincture of iodine thrice daily. She reported one more ter-
tian chill. She was seen within two hours of each of these reported
attacks, but had no fever either time. Case VII. had well-marked chills
on the first and third days of observation. He was given thirty drops
of the tincture thrice daily, and remained free from fever after the second
attack. Case XXXI. gave a history of double tertian ague of four weeks'
duration. He was given thirty drops of the tincture thrice daily. He
reported a chill during each of the first two afternoons of his stay in the
hospital, but was contradicted by the Ward master. His temperature
taken four hours after each asserted chill, was 100.6° and 98.4°. Case
XLVIII. took the tincture in doses of thirty drops four times daily for
three days, when it had to be stopped on account of the nausea it occa-
sioned, even in reduced doses. He had a chill during the evening before
treatment was begun, with a temperature of 102.8°, and chills on the
second and third days, with temperatures of 104° and 103.4°. Although
the medicine was now stopped on account of the nausea, he had no more
ague during the period he remained with us.

We have hesitated to report Cases II., III., IX., and XXXI. of these
nine " cures," but give them, desirous of yielding to the " iodine treat-
ment of malarial fever" all the credit it can possibly deserve. Cases I.,
IV., XXXV., and LVIII. were cured after a treatment lasting more than
three days. Case I. had a chill daily for six days, with temperature

1883.]

Atkinson, Woods,' Iodine in Malarial Fevers.

varying from 103° to 105.2°. During five days he took twenty-five drops,
afterwards thirty drops of the tincture thrice daily. On the seventh and
eighth days he had evening temperatures of 100.6°, but no chill. After
this his temperature remained normal. Case IV. had, for six successive
days, a chill in the morning of one day and in the afternoon of the next
(double tertian), with temperatures varying from 102° to 103°. On the
seventh day he missed his chill, but had one on the evening of the eighth
day. This was his last. He took at first fifteen drops thrice daily. The
dose was gradually increased to twenty, twenty-five, and thirty drops
thrice daily. Case XXXV. took forty drops four times daily, and had a
chill on each day for four days, with temperatures of 102.2°, 104°, 102°,
102°, after which it became normal. Case LVIII. took twenty drops of
the tincture thrice daily. He had chills on the second and fourth days,
with temperatures of 105° and 102°. On the sixth day he had a tem-
perature of 100°, but no chill, and became convalescent.

The remaining three cures, were of remittent fevers. In two of these
iodine seems to have had an immediate influence, the temperature falling
to normal soon after beginning treatment, remaining so, however, but a
short time. The exacerbations soon recommenced, and the final reduc-
tion to normal condition in all three cases was accomplished by a gradual
reduction of the violence of the exacerbations and of the height of the tem-
perature. Case XXI. took thirty, drops four times daily. After two
doses his temperature fell from 102.4 to 99.4° on the morning of the
second day. That evening it rose again to 100° ; next evening to 102.7° ;
on the fourth evening it was 102° ; on the morning of the fifth day it was
101.2°. It then fell to normal and remained so for six days, when the
patient was discharged. This man had had malarial intoxication for
three months. It is, therefore, not impossible that the attack was a mani-
festation of chronic malaria with spontaneous subsidence. We credit the
tincture of iodine with the cure, however. Case LXI. took twenty drops
of the tincture thrice daily. His thermal line was : First day, M., 101°,
E., 104°; second day, M., 98.2, E., 102.4°, It now became normal, and
remained thus for two days, when it again reached 101°, and came down
gradually as follows, viz.: 101°, 99.4°, 99°, normal. The remedy was
taken throughout. Case XXVIII. took thirty drops four times daily.
His morning temperature was always from 1° or 2° below that of the
evening It became normal on the sixth day. As shown by the following
thermal line, the evening temperature fell to normal on the eighth day:
' 103.6°, 103.3°, 103°, 102.1°, 101.8°, 100°, 100°, 99.2°. This case
shows clearly the gradual reduction of which mention has been made, and
which will be further observed when relapses of remittent fever are con-
sidered.

Thirteen cases, eight intermittent and five remittent fevers, seemed at
first to be benefited by the iodine, but the improvement was not perma-

(.8

Atkinson, Woods, Iodine in Malarial Fevers.

[July

nent. Of the intermittents, six were quotidian and two tertian. Of the
quotidian fevers, Case XVIII. took twenty drops of the tincture four times
daily. The chills ceased after three days and recurred after five days,
the patient taking the remedy all the while. On the fifth day at the usual
chill time, the temperature was 101°, and at the same time next day it
was 103°. This case resisted all remedies, including cinchonidia and qui-
nia, for, after we ceased to give the iodine, we gave these agents, check-
ing the paroxysms at once, but subsequently a relapse occurred. Case
XLI. took thirty drops of the iodine four times daily and had three chills,
with temperatures of 106°, 104°, 102.8°. For six days after this last
chill he continued to take iodine. He was then discharged. He was re-
admitted on the fourteenth day after his last paroxysm, with a return of
his chills. He was again given iodine in twenty drop doses of the tinc-
ture thrice daily. He had two paroxysms, but no more while under
observation. Case XLV. had two chills, with temperature of 104°,
while taking the tincture of iodine in thirty drop doses four times daily.
The attack did not recur on the third day, but he had chills on the fourth
and fifth days, with temperatures of 104° and 104.8°. The sulphate of
cinchonidia was now given, whereupon the paroxysms ceased, and did not
return. Case XL VI. took thirty drops four times daily. He had one
chill, with a temperature of 104°. He remained without attack until the
fifth and sixth days, when he had chills with temperatures of 104. G 3 and
101.8°. On the sixth day he was given cinchonidia. He had a chill on
the seventh day, and no more during the week he remained under obser-
vation. Case XLIX. had two quotidian chills while taking twenty drops
thrice daily. He continued to take iodine for four days. Xine days after
the last paroxysm he had another attack. Under the use of cinchonidia
he had no further trouble. Case LII. had three daily chills, and took
thirty drops of the tincture four times daily. He escaped a chill upon the
fourth day, but bad one on the fifth day, with a temperature of 104.2°.
He also had one on the sixth day. Iodine was now discontinued and sul-
phate of cinchonidia given. After this there was no further trouble. Of
the two relapses of tertian intermittents, Case XVI. took thirty, twenty,
fifteen, and ten drops of the tincture thrice daily, the dose being gradually
reduced on account of nausea. He had one paroxysm, with a temperature
of 100.2°, after beginning to take the iodine. On the seventh day (after
nausea had compelled us to discontinue the medicine), and nearly eleven
days after the last paroxysm, he had a chill with a temperature of 101°.
Cinchonidia was now given. He had a chill upon the first day, but
no more for the three months during which he remained in the institu-
tion. Case LIII. showed rather a postponement of the attack than a
relapse. He had chills on the second, fourth, sixth, and eighth days,
while taking thirty drops of iodine four times daily. He had no chill

1883.] Atkinson, Woods ,, Iodine in Malarial Fevers. 69

upon the tenth day, but the chills recurred upon the eleventh and thir-
teenth days, when cinchonidia was substituted with prompt results.

Each one of the five cases of remittent fever was taking iodine at the
time of the relapse. As may be seen by the thermal records that follow, the
violence of the exacerbations was becoming daily less, and the tempera-
ture was gradually falling towards normal. The relapse was shown by a
sudden rise of temperature. Case XXIII. took the tincture for five days,
during which his evening temperature ranged from 99° to 100°. His
morning temperatures were as follows : viz., 102°, 101.4°, 101°, 100.4°,
99°. Upon the sixth day, the morning temperature was 100.6°, the
evening temperature 102°. Cinchonidia was now given. He had one
more paroxysm with a temperature of 100.6°, and that was all. Case
XXXIX. had a temperature of 100°, and gave a clear history of previous
malarial disease. Thirty drops of the tincture were given four times
daily, and the temperature fell to normal limits within four days. For
the next three days it was as follows, viz. : — .

5th day, A. M., 100° ; P. M., 100°
6th " " 100.2; " 102
7th << " 100.7; " 102.3

Cinchonidia was substituted, and the temperature became normal at
once, and remained so during the week the patient continued under
observation. Case XLIII. is best represented by the thermal line : —

1st day, P.

M.,

104.8°.

2d " A.

102°; P.M.,

104.4

3d "

102; "

103.6

4th "

101; "

102

5th "

99.4; "

101

6th "

100;

102.6

7th «

98.6; "

103

8th "

t i

100

Cinchonidia was ordered, and during the four days he remained in
the hospital he had no more fever. Upon a single occasion during the
treatment the patient's urine contained albumen. Case XLVII. took
thirty drops of the tincture four times daily. For four days there was
no improvement, the morning temperature varying between 100° and
100.6° ; the evening temperature between 102° and 103.4°. During the
next two days there was a gradual fall, as follows, viz. : During the even-
ing of the fourth day, 102.8°. Fifth day, A.M., 102° ; P. M., 100°.
Sixth day, A. M., 99.8° ; P. M., 101.2°. During the next three days the
fever continued with morning temperature from 99° to 100°, and evening
temperature from 100.6° to 101.2°. On the morning of the ninth day
the temperature was 98.4°, but during the evening it reached 103°.

Atkinson, Woods, Iodine in Malarial Fevers.

[July

Sulphate of cinchonidia was now given ; the fever ceased at once, and did
not recur during the two months he remained in the institution. Case
LI. had had malarial intoxication a long while. He took thirty drops of
the tincture of iodine four times daily. The subjoined table shows the
gradual reduction of the temperature : —

1st day, A.M., 102° ; P.M., 103°

09.4;

103

101

102

4th

99.4;

101

5th

98.4;

((

100

The temperature varied between 98-100° for four days, after which
it increased ■ for three successive evenings, as follows: 101°, 100.4°,
101°. Sulphate of cinchonidia was substituted for two days, without
affecting the temperature, which on the eleventh day was 102° in
the morning, and 102.8° at night. Sulphate of quinia was then given.
The temperature became normal within forty-eight hours, and remained
thus during the succeeding eight days of his stay in the hospital. This
patient had splenic and hepatic engorgement. Each region was exceed-
ingly tender on pressure. This tenderness the local application of the
tincture seemed to benefit. In all these cases there was complaint of
nausea, though vomiting was not produced. The addition of ten drops ot
laudanum to each dose secured toleration for the iodine in nearly all cases,
and enabled us to continue its administration during the five days of trial.

Four cases, however, suffered so much nausea and vomiting that we
were forced to discontinue the administration of iodine, while the physical
prostration of a fifth patient impelled us to abandon its use before the period
of trial was completed. Case X. had two tertian chills, for which he took
twenty-five drops thrice daily. Upon the fifth day he suffered intense
nausea, vomiting the iodine as soon as taken, even in fifteen-drop doses.
He had a third chill upon the seventh day. Case XIII. commenced
treatment by taking twenty drops thrice daily. Xausea set in, and doses
of only ten drops were rejected. Troublesome diarrhoea also appeared,
but yielded to opium. He had chills upon three successive days while
taking iodine. Case XX. was first given thirty drops four times daily.
After the first day he was unable to retain the drug, though reduced to
fifteen-drop doses. After a day's rest the iodine was resumed in ten-drop
doses with tincture of opium, but was always rejected. While taking the
tincture he had four daily chills, with temperatures of 102°, 101°, 101.7°,
102.7°. For several days he vomited everything. Sulphate of cincho-
nidia was given as soon as it could be retained. During the following
three days his temperature remained about 101°, and he developed puffi-
ness of his eyelids, swelling of the abdomen, and albuminuria. The last
symptom disappeared after four days, and convalescence was established

1883.] Atkinson, Wood s ,. Iodine in Malarial Fevers.

without delay. Case XXXIII. took for three days thirty drops of the
tincture four times daily. At the end of this period he became so pros-
trated that we were compelled to stop it. During its administration he
had a chill each day with temperatures of 102.4,° 104.5°, 102°. Cin-
chonidia was substituted. He had a chill the next day, but no more.
One more case must have especial mention. This patient, a young man,
took thirty drops of the tincture of iodine four times daily. He had
chills on the second and fourth days, but none on the sixth day, though he
suffered greatly from nausea and vomiting. The dose was reduced to ten
drops with laudanum, but he became quite unable to retain it. Swelling
of the ankles and abdomen developed. An examination of the urine gave
sp. gr. 1.008 ; intense iodine reaction, although the last dose had been
given three days previously; no albuminuria. Two days later there were
marked ascites, with general anasarca and pronounced albuminuria. The
microscope revealed hyaline and finely granular tube-casts in large num-
bers. The symptoms of acute tubular nephritis developed. Albuminuria
was present during eleven consecutive days, and was absent during the
following six days. It was again present in minute quantities for two or
three days, after which several examinations made during the following
two months failed to discover it.

Four cases left the hospital before we had completed the trial of iodine.
Case IV. took thirty drops four times daily, and had a chill each day for
three days. He then left without permission. Case VIII. took thirty
drops three times daily. He had three tertian chills, when he demanded
his discharge and left. These cases should be classed with the failures.
Case XXIX. had normal morning temperatures, and evening tempera-
tures of 100-103°. By gradual reduction, while still taking iodine, this
reached normal limits by the fourth day. He left the hospital the following
day, and we were unable to determine the permanence of the cure. Case
XLII. had normal morning temperatures, but his evening temperatures
for five days were : 102.4°, 100°, 100°, 102.8°, 99°. This last was taken
at four o'clock P. M., and indicated a rise of 1° in six hours. He took
thirty drops four times daily. He left the hospital without warning.

We have now considered 39 of our 76 cases, and have certainly allowed
to iodine all its most enthusiastic supporters could demand. We have
given so much space to the "cures" and ''relapses," because we wished
to show in what manner iodine exercises the feeble influence it seems to
exert as an antiperiodic. These 39 cases, it seems to us, fully demonstrate
. the feeble antiperiodic powers of iodine. The very work it accomplishes
condemns it. In the 37 cases which follow we were unable to see the
slightest benefit from its use. These cases compose 20 quotidians, 7
tertians, 3 double tertians (a paroxysm on each day, but corresponding
in time and severity on alternate days), 2 triple tertians (two paroxysms

Atkinson, Woods, Iodine in Malarial Fevers.

[July

on alternate days, and one on other alternate days), and 5 cases of remit-
tent fevers.

Of the quotidian fevers : Case XI. took twenty-five drops for nine days.
His evening temperature varied from 102° to 105° ; morning temperature
from 98° to 99°. Cinchonidia was substituted, and the chills ceased at
once. Case XII. took twenty-five drops thrice daily. He had daily chills
for five days, with temperature from 102° to 103°. After this he had
evening temperature of 101° to 102° for four days without chills. Cincho-
nidia effected an immediate cure. Case XVII. took thirty drops four
times daily, for five days. He had a chill each day, with temperatures
from 102° to 105°. He was cured at once by cinchonidia. Case XXV.
gave the same history as the preceding case. He was given thirty drops
four times daily for five days, and had a chill each day, with temperature
from 102° to 106°. He also was completely cured by cinchonidia, and
at once. Case XXVII. took the same doses as the preceding patient.
He had five daily chills, with temperature of 102° to 103°. Cinchonidia
was then given with prompt relief. These 6 cases are typical of 13 more
of the 20 cases of quotidian fever. Of these 13 cases, XXVI., XXXIV..
XLIX., and LVI. took thirty drops four times daily for five days. In
XLIX. it produced great nausea on the fourth day. The 9 other cases,
LX., LXIIL, LXIV., LXVL, LXX., LXXL, LXXIIL, LXXV..
LXXVL, took twenty drops thrice daily. These latter cases were treated
after several cases of albuminuria had been observed, and we reduced the
dose in consequence. All of them were able to take the iodine for
five days, although some were fortified against its unpleasant effects by
laudanum or carbolic acid. In each case there was a chill each day.
the temperatures ranging from 101° to 106.5.° Cinchonidia checked
every one of them. Case LVII. was the last of this series. Treatment
was begun by the administration of thirty drops four times daily. This
dose nauseated on the third day, and was reduced to twenty-five drops,
with ten drops of laudanum to each dose. This he took with difficulty until
the fifth day. He had daily chills in the afternoon, with temperatures of
104°, 104.6°, 101°, 103°, 102°. Cinchonidia promptly arrested the
paroxysms, and he had no chill during the subsequent eighteen days, dur-
ing which he remained under observation. The day after we discontinued
the iodine his urine showed traces of albumen. This disappeared two
days later, and did not return.

Of the cases of tertian ague not benefited by iodine, Case V. took fifteen
drops thrice daily. This was increased to twenty-five drops on the third
day, and to thirty drops, four times daily, on the fourth day. This was
one of our first cases, and we administered the drug for thirteen days.
For nine days the fever was tertian ; during the last four days he had a
chill each morning. The disease yielded at once to cinchonidia, and
did not return. Case VI. was also one of our early ones, and we gave

1883.] Atkinson, Woods,' Iodine in Malarial Fevers.

the tincture for ten days. As in the preceding case, the rpatient grew
-worse instead of better. After the first chill he took fifteen drops three
times daily, and after his second chill twenty drops four times daily. On
the fifth day, after a chill and high fever, the dose was increased to thirty
drops four times daily. He had chills upon the sixth and eighth days, and
upon the latter date, the dose was made thirty-five drops four times daily.
He had a chill upon the next day, and the iodine was discontinued. Cin-
chonidia cured him at once. Case XXXII. took thirty drops of the tinc-
ture four times daily. He had on the first, third, fifth, and seventh days
chills, with temperatures of 104.8°, 105.8°, 102.4° (seventh day not
taken). Cinchonidia was substituted after the last chill, and he had no
more. Case XXXVII. had chills on the first, third, fifth, and seventh days,
with temperatures of 101° to 104°. The dose of the tincture at first was
thirty drops four times daily. Diarrhoea appeared upon the fourth day,
and nausea on the fifth, when the dose was reduced to twenty-five drops,
with ten drops of laudanum. Abdominal pains were complained of. Cin-
chonidia stopped his chills at once, but there was a relapse later. Case
XL VIII. took twenty drops thrice daily. He vomited this dose on the
second day, but the addition of tincture of opium enabled him to retain it
with difficulty. On the first, third, fifth, and seventh days he had chills,
with temperatures from 102° to 103.6°. Cinchonidia stopped them at
once. Case XXXVIII. took thirty drops, four times daily, for six days,
and had chills on the second, fourth, and fifth days, with temperatures
of 100° to 101°. These ceased as soon as cinchonidia was given. Case
LXXII. took twenty drops thrice daily. He had chills on the mornings
of the first, third, and fifth days, with temperatures of 103.8°, 103.2°,
103.5°. Cinchonidia was given with immediate relief.

Of the double tertians, Case XIX. took thirty drops of the tincture four
times daily. On the first, third, and fifth days he had chills during the
afternoon, with temperatures of 101.4°, 103.2°, 105.2°. On the second,
fourth, and eighth days his chills began about 7 o'clock A. M., with tem-
peratures of 105°, 102.6°, 103°. All evidence of the malady disap-
peared upon the administration of cinchonidia. Case XXIV. was,
strictly speaking, more properly a " duplicated tertian" than a " double"
tertian, as the two paroxysms occurred on the same days. This patient
took thirty drops four times daily for four days ; on the fourth day the
dose was reduced to twenty drops, on account of nausea. On the second,
fourth, and sixth days he had morning chills with temperatures of 100°,
102°, 102°, and on the afternoons of the same days more violent chills,
with temperatures of 106.4°, 106.2°, 104°. After beginning to" take
cinchonidia he had one chill only, and then had no more trouble. The
iodine was discontinued after the fifth day. Case LIX. had, on the
evenings of the first, third, and fifth days, temperatures of 100°, 101°,
102°, without chills. On the afternoons of the second, fourth, and eighth

Atkinson, Woods, Iodine in Malarial Fevers.

[July

days he had chills, with temperatures of 100°-102°. Cinchonidia was
given, and he had no more chills.

Of the triple tertians, Case LXV. took twenty drops three times daily.
On the first, third, and fifth evenings he had temperatures of 101°, 100.8°,
100.4°, without chills. On the second, fourth, and sixth days he had
morning temperatures of 101°, 100.8°, 102°, and on the afternoons ol
the same days he had severe chills, with temperatures of 105°, 104.4°,
104.8°. In spite of cinchonidia (now given), he had on the eighth day
a morning temperature of 103°, and an evening temperature of 102.8°,
but no chill. This was his last attack. Case LXXIV. had a very
violent attack, with great prostration. After taking thirty drops of the
tincture of iodine thrice daily, he vomited his medicine, but took after
this fifteen-drop doses with difficulty. For five days he had a chill each
afternoon, with temperatures of 103.4°, 103°, 103°, 101.6°, 103°. On
the second and fourth days he had, in addition to his afternoon chills, morn-
ing temperatures of 100.2° and 101.6°. He now took cinchonidia, and
missed his chill on the seventh day, but it came on the evening of the
eighth day with a temperature of 102.5°. This was the last.

Iodine failed to benefit five cases of remittent fever. Case XIY. took
at first twenty-five drops of tincture of iodine thrice daily. On the third
1 day the dose was increased to thirty drops four times daily, but was
reduced on account of diarrhoea. For five days his morning temperature
was 99.4° and less. The evening temperature varied between 101°-102°.
Cinchonidia was given, and the patient at once got well. Case XXII.
was the second patient who resisted both cinchonidia and quinine after
the failure of iodine. His fever seemed to wear out at the end of three
weeks. While taking thirty drops four times daily, the thermal line was :
1st day, A. M., 100° ; P. M., 98°. 2d day, A. M., 98.6° ; P. M., 101.
3d day, A.M., 102°; P.M., 101.8°. 4th day, A. M., 99° ; P.M., 104.6°.
5th day, A. M., 99.4° ; P. M., 100.6°. 6th day, A. M., 98.4° ; P. M.,
101°. After cinchonidia wTas substituted, the exacerbations became even
greater. Quinine was next given, and the temperature fell only gradually
to normal, reaching normal limits not until the end of the third week.
Case XXX. began to take thirty drops four times daily. This had to be
reduced to twenty drops on account of nausea. The subjoined thermal line
shows no evidence of the " gradual reduction" already spoken of, but there
seems to have been an intermittent element in the morning temperatures :
1st day, A.M., 100.7°; P.M., 104°. 2d day, A. M., 98.4° ; P.M., 103°.
3d day, A. M., 101.6° ; P. M., 104°. 4th day, A. M., 99° ; P. M., 104°.
5th day, A. M., 101° ; P. M., 103.4°. 6th day, A. M., 99° ; P. M., 103°.
7th day, A. M., 100.2° ; P. M., 101°. Cinchonidia was substituted for the
iodine on the sixth day with prompt relief. Case LV. took thirty drops
four times daily. On alternate evenings, for six days, his temperature was
100-101°. In spite of cinchonidia, it reached 101° on the eighth day,

1883.] Atkinson, Woods, Iodine in Malarial Fevers.

but he had no subsequent trouble. Case LXVII. took twenty drops of
tincture of iodine thrice daily for six days. His thermal line was : 1st
day, A.M., 99.4°; P.M., 103.6°. 2d day, A.M., 102.6°; P.M.,
103°. 3d day, A. M., 98° ; P. M., 97.8°. 4th day, A. M., 98.4° ; P.
M., 103°. 5th day, A. M., 97.6° ; P. M., 99.7°. 6th day, A. M., 99.7° ;
P. M., 102.6°. The patient became entirely well immediately after tak-
ing cinchonidia.

This concludes the summary of our work. Before drawing our con-
clusions, we wish to answer an objection which may possibly be brought
against our cases. This objection, indeed, has already been made by Dr.
Gibbons, in the Pacific Medical and Surgical Journal, against Dr. Fri-
denburg's report adverse to the claims of iodine as an anti-periodic.
Substantially it is this : The dose given is too large, produces nausea and
vomiting, preventing thus absorption, and so enforcing failure. To this
we would reply that of our sixteen " cures" nine were effected while the
patients were taking thirty drops four times daily, and in two of these
the dose was gradually increased from fifteen and twenty drops thrice daily
after these latter doses had failed to benefit. The severe cases, the cure
of which we have credited to iodine, all took from twenty-five to thirty
drops four times daily. We can also state that, while complaints of nausea
were heard from thirty patients, no case is recorded as a failure where
the iodine was not retained, and where its absorption was not made
manifest by abundant evidences of its presence in the urine. Finally, it
will be remembered, our dose of thirty drops is a little less than fifteen
minims, the dose with which Dr. Morrison obtained his excellent results.
(Md. Med. Journal.}

When we add that in a few cases the local application of iodine seemed
to lessen the hepatic and splenic pains, we have described all the good we
could derive from its use in acute malarial poisoning, As to its utility in
chronic malarial poisoning we are not able to speak. Many of its advo-
cates have said that here it does its great work in preventing the paroxysms
which occur at irregular intervals, and in curing and preventing the splenic
and hepatic changes. This we were in no position to investigate. -Not all
its supporters, however, hold this view by any means. Some claim for it a
power in acute malaria superior to that of Peruvian bark ; others are con-
tent with putting the two agents upon an equality. Our experience has
not confirmed either of these statements. We are enabled to compare, in
a measure, Peruvian bark and iodine, inasmuch as we gave cinchonidia or
quinine to 52 of our cases, composed of 12 of the 13 relapses after bene-
fit from iodine, 2 of those in whom the drug set up intolerable nausea, 1
to whom we gave cinchonidia because he was failing, and the 37 cases
who were not benefited in five days.

Comparing, then, the two agents, we find the following to be the results
of our investigations : I. Of 52 cases of acute malarial fever which iodine

Atkinson, Woods, Iodine in Malarial Fevers.

[July

failed to cure, cinchonidia arrested 38 promptly, and 10 after one paroxysm,
but allowed a relapse in one case later. One case resisted cinchonidia for
two days, and yielded at once to quinine. One continued to have a tem-
perature of 101° for three days, but was suffering at the time from kidney
trouble (XX.), while the last two resisted both cinchonidia and quinine, and
wore themselves out in three or four weeks. (In regard to these last, one
naturally thinks of typhoid fever. The duration of the fever, however,
was the only characteristic of typhoid. Since this was the case, we made
a diagnosis of remittent fever, although we failed to cure with quinine.)
II. As to relapses, since our patients left early, we cannot speak with much
assurance, specially as regards relapses after cures. However, of iodine
this much we know : of 29 cases in which the slightest benefit accrued
after the use of iodine, 13 relapsed, the intermittents on the 5th, 7th,
12th, and 14th days, while in the remittents the medicine seemed sud-
denly to lose all control over the fever.

A word about albuminuria. We found it in four cases. In each case, an
examination of the urine, previous to giving iodine, had shown it to be
healthy. In two of our cases the albumen was found only once, and in the
other two it formed two very troublesome complication. The weight of au-
thority seems to hold that albuminuria is not an ordinary complication in
acute malarial poisoning. Dr. Bartholow {Practice of Medicine) speaks
of a nephritic form of pernicious intermittent fever, and also states that
albuminuria may result from chronic malarial poisoning. Bartels {German
Clinical Lectures, New Syd. Soc, 1876, p. 211) says that, "in his expe-
rience malaria is the most frequent cause of chronic inflammatory enlarge-
ment of the kidney." In regard, however, to the occurrence of albumi-
nuria in the course of an intermittent or remittent fever, Dr. McLean
{Reynolds' 's System of Medicine) says, " it is extremely rare;" of remittent
fever, Prof. DaCosta says (in his Medical Diagnosis), "at no stage does
the urine contain albumen." In the Philadelphia Medical News of
December 9, 1882, Dr. Fairfax Irwin (U. S. A.) gives an account of 90
cases of remittent fever which he treated in the South. Albuminuria
did not occur in a single case. In view of these statements, in view of
the fact that albumen was found in the urine after the iodine had been
used, and since we always found the iodine in the urine while we were
giving it, we are led to suspect that the iodine and albuminuria may
stand in the relation of cause and effect.

There was a noticeable absence of pronounced " iodism" in our cases.
Nausea, a few cases of diarrhoea, and some complaints about a " stuffy
feeling like a cold in the head," and a "bad taste in the mouth" were
the only symptoms of the malady with which we met.

Finally, from our experience we would draw the following deductions
as to the use of iodine in acute malarial poisoning : —

(1) In intermittent fevers it has some feeble influence in controlling the
paroxysms.

1883.] Minor, The Field of Vision. 77

(2) It takes usually from three to eight days to exercise this influence.

(3) In cures effected there is great danger of a relapse ; certainly as
great as with Peruvian bark.

(4) It is certain to add to any existing diarrhoea or nausea, and is liable
to cause each, if they do not already exist.

(5) In remittents, its effect, if any, is seen in a slow and gradual reduc-
tion of temperature, and this reduction is liable to sudden interruptions.

(6) In both forms of malarial fever it is infinitely inferior to either
cinchonidia or quinine : certainly as regards the immediate control of the
fever, and, as far as we were able to judge, as regards relapses also.

(7) From an economic point of view, the slowness and uncertainty of
its action make its use in hospital practice fully as expensive as Peru-
vian bark.

(8) There seems to be some ground to believe that it can cause albumi-
nuria.

(9) In the large majority of cases of ordinary acute malarial poisoning
it has no influence whatever.

Article IV.

The Field of Vision. James L. Minor, M.D., Pathologist and Assistant
Surgeon to the New York Eye and Ear Infirmary.

It is well known that, when the eye is fixed upon a stationary object,
we see clearly only that part looked directly at ; while surrounding zones
are seen with increasing indistinctness as we pass from the point of fixa-
tion to the periphery of the view, until a point is reached where every-
thing fades from our sight. The area thus obtained with a single eye is
the field of vision, which is a map of the visual power of the entire retina,
from the macula lutea to the ora serrata. The visual field (which we will
designate V. F.) furnishing, as it does, a reflected (inverted) image of the
perceptive power of the whole eye, is interesting in health and important
in disease ; for we here have to deal with an organ intimately connected,
both anatomically and physiologically, with the brain, that participates
with many, if not most, of the pathological processes affecting the latter,
and shows such participation in a clear and demonstrable manner. Various
methods have been resorted to for mapping out the V. F. in such form as
to admit of its being recorded on paper for permanent preservation. The
fundamental principle is to have the eye under examination fixed upon a
stationary point in front of it, while a movable object establishes the ex-
treme limit of visual perception for the various meridians of the eye, thus
mapping out the boundary of the V. F. A rough but convenient way is

Minor, The Field of Vision.

[July

to have the patient look at the tip of one of the examiner's fingers, held
12r/ in front of the eye, while, with a finger of the other hand, the peri-
pheral limit of the V. F. is established. A still better method is to have
the patient look at a small spot on a blackboard, 12" from the eye, while
the V. F. is mapped out by a bit of white paper V sq. in a holder, and
recorded with chalk on the blackboard, whence it can be transferred to
paper. Both of these methods are objectionable. The first is too rough
and inaccurate, and the second presents difficulties that it is hard or im-
possible to overcome. The blackboard is a plane surface ; hence the
peripheral test object, as it is carried from the point of fixation, will also
be removed from the eye, so that it will often be necessary to increase the
size of the test object to make it visible at so great a distance as it is neces-
sary to place it. And, again, the limit of the Y. F. in many eyes reaches

Fig. 1.

1883.]

Minor, The Field of Vision.

a point 90° from the centre of fixation ; thus forming a right angle with
the visual axis, which would bring about parallelism between the black-
board and the limit of the V. F. in this locality.

The only reliable method of taking the V. F. is with a perimeter, and
of these there are many varieties to choose from. The essential part of a
perimeter is an arc of a circle, 180° in extent, and preferably of VI"
radius, pivoted at its centre to an upright, which allows it to be turned to
the different meridians desired. Beginning at the centre with 0°, each
limb of the semicircle is marked off in degrees, up to 90°, at its end. A
chin-rest is important, and it is convenient to have on the rear of the
arc a stationary disk, with a series of radii, going around from 0° to 360°,
with an indicator which moves with the arc, to show the meridian occu-
pied by the arc in any given position. Such an instrument has been
made for me by Mr. Schrauer of this city. It combines all of the require-
ments of a perfect perimeter with simplicity and cheapness.1 A glance at
the cut will render further description unnecessary. (See Fig. 1.)

To take the V. F., the patient places his chin on the chin-rest, and'
looks with the eye to be examined (the other eye being covered) at the
small spot on the centre of the arc. A piece of white paper, V sq. in a
simple holder, is moved from the periphery of the arc towards the centre,
and the point at which it is first seen is noted. This is done with each
limb of the semicircle in the desired meridian, usually six, and these
measurements are recorded on a chart made for the purpose, which is laid
out in radii and circles that are numbered so as to correspond to the peri-
metric measurements. (See Fig. 2.)

The normal central acuity of vision is in marked contrast with that in
the periphery of the V. F. At 12/r from the eye an area in the Y. F.
3" by ^" would include that portion possessed of normal (central) vision.
Within this space the normal eye can distinguish an object which sub-
tends an angle of one minute upon the retina. An object subtending an
angle of this extent, having been taken as the unit of visual acuity, it be-
comes an easy matter to measure the amount of reduction in sight when
it is below the normal, by comparing the extent of the angle formed by
the test-object used with that which is taken as the normal standard, i. <?.,
one minute. The size of the object (measured by the angle that it forms
on the retina) will increase as the visual acuity diminishes.

For testing the acuity of vision in eccentric portions of the Y. F., I
used slips of white paper, on each of which were drawn three black square
spots, the space between each spot being equal to the diameter of the
spots which it separated. Each spot was of such size as would subtend
an angle of one. minute upon the retina; when viewed at the distance in
feet, indicated by the number on the slip,2 e. g., No. 1, one foot from the

1 A simplification of Forster's instrument.

2 These squares represent cross-sections of the limbs ot Snellen's test-letters.

Minor, The Field of Vision.

[July

eye would subtend an angle of one minute; No. 2 an angle of one minute
at two feet ; No. 100 at one hundred feet, etc. etc. Only normal eyes
were examined. First, the limit of perception was mapped out, and this
gave the quantitative field. Next, the qualitative field, or that portion of
V. F. possessed of form perception, was determined in the following way:
The slip of paper with spots which would subtend an angle of one minute,
when seen at a distance of two hundred feet, and marked 200, was slowly
brought from the periphery of the arc of the perimeter towards the centre,
and the point at which the spots were recognized as three separate dots was
noted, and vision at that point was set clown as ^ho > f°r an 00ject which,
when in the centre of the V. F., could be seen at 200 feet, had to be
brought to a point one foot from the eye before it was recognized in this
portion of the V. F. This was repeated for the various meridians, and
thus the zone in the Y. F., possessing vision of -^hoi was determined.
Then the next number, 100, was treated in the same manner, and the
points at which its spots were recognized being noted, that portion of the
V. F. possessing vision of was established. This was repeated for all
of the different sized spots. The extent of each zone, in degrees upon the
perimeter, is given in the following table : —

No.

of slip.

Outer or
temporal
side of V. F.

Inner or
nasal side
of V. F.

Upper
part of
V. F.

Lower
part of
V. F.

Vision is

seen at

00
1

■

0O
1

00
1

From centre

3
4

1 1 '

H
%k

it n

- "

l
¥

5
6

3
4

3
5

3
4

it a
it tt

l
S
1
6

8
10

i (

6
7

7 .

6
7

it a

i
1

1 0

a
t 1

8
10

1 5
1
20

30
40

15
20

15
18

15
17

3 0
1
40

50
70

t i

25
33

23
28

20
25

a it
tt a

i
5 0
1

100
200

1 1

38
50

34
40

30
35

30
40

it tt

TtJO
270

This table is the averaged result of the examination of twrelve eyes ;
and it differs but little from those obtained by Landolt, Dorr, Konsg-
shofer, and others. An absolute standard cannot be established, but the
above may be taken as a guide to what the eccentric vision should approach.

The foregoing method of testing was adopted because it was desired
(1) to obtain results which would admit of comparison with the usual
measurements of central vision, and (2) to eliminate the uncertainty

1883.] Minor, The Field of Vision. 81

which attaches itself to tests in which the recognition of letters is taken
as the standard. Test-letters are sd*eonstructed that the 'stroke or limb
of each letter shall, when at a given distance from the retina, subtend an
angle of one minute thereon ; and the square spots used in these experi-
ments were sections of a single limb or stroke of the test-letters in most
general use (Snellen). Thus, the tests for central and peripheral vision
were made to practically correspond. And as a clear recognition of a
letter requires that the stroke or strokes composing it shall be clearly seen,
it is necessary that a large part of the V. F. be occupied by the letter;
and this involves an association of retinal zones, possessed of different
degrees of visual acuity, for the recognition of a single object, while the
squares represent that part of the letter which is taken as the unit of its
measurement. Another advantage offered by the squares is that the accu-
racy of the tests can be verified by covering one or more of the spots
during an examination of any zone. Certain variations will be found in
the normal eye, dependent upon such conditions as differences in illumi-
nation, intelligence, and attention of the patient, and the amount of prac-
tice and education of the retina, as well as the patienc© of the examiner.

The cause of reduced vision in peripheral parts of the retina is to be
explained on both optical and physiological grounds. When light passes
obliquely into the eye, the nodal point is so changed as to prevent the
formation of a distinct image ; and the periphery of the retina is less
experienced, and is inferior in anatomical construction to the central
portions.

Not only is our form-sense much more acute in the centre of the V. F.
but our perception of colour is far sharper here than elsewhere. Indeed
our ability to distinguish colours diminishes so rapidly as we pass from
the centre, that most observers claim that colours cannot be recognized in
the extreme periphery of the V. F. Landolt, however, proved the falsity
of this view, when he demonstrated the fact that the red, green, or blue
of the spectrum, when isolated from other colours, in a darkened room,
could be distinguished in the outermost limit of the V. F. It is not
necessary to resort to the spectrum to prove this, for I have found that the
colour of pure bright transmitted light, such as is obtained when the light
from an argand burner passes through a piece of red, green, or blue glass,
in a darkened room, is quickly recognized in the extreme limit of the V.
F., at a distance of 12r/ from the eye.

To test the colour-field, a card of the 'desired colour, about 1" sq.,
is slowly brought from the periphery toward the centre, and the point at
which its colour is first recognized is noted. This being done for the
various meridians,. and the points united, we have the extent of the colour-
field. It will be found that a zone in the periphery of the V. F. exists, in
which colours are not recognized by this test. It is due to a lack of
purity and intensity of the colour, and not to colour-blindness. It will
No. CLXXI July 1883. 6

82 Minor, The Field of Vision. [July

be also noticed that certain colours can be distinguished at a greater dis-
tance from the centre — further in the periphery of the V. F — than others.
The field for blue is most extensive ; next comes red, and finally green.
It has been stated by various Americans who have written upon this sub-
ject, that the field for green is more extensive than that for red ; and
some European writers have fallen into the same error. (See Fig. 2.)

Fig. 2.

Having studied with some detail the acuity of vision in the normal V.
F., it may be of interest to glance at some of the affections in which peri-
pheral vision is reduced or destroyed. It is hardly necessary to mention
that lesions of the eye, involving destruction or loss of function of the
retina, are accompanied by blindness in that part of the V. F. correspond-
ing to the retinal lesion. Hence in many cases, and especially those in
which a satisfactory ophthalmoscopic examination cannot be made, the
V. F. is of material assistance in deciding the extent or locality of an
injury inflicted by, or the presence of, a foreign body in the globe ; a
retinal detachment, intra-ocular tumours, or hemorrhages, and gross cir-
cumscribed pathological changes in the inner tunics of the eye. An em-
bolism of one of the retinal- vessels will be accompanied by blindness in
that portion of the V. F. corresponding to its distribution. (The upper
part of the V. F. corresponds to the lower portion of the retina, the tern-

1883.]

Minor, The Field of Vision.

poral side of the V. F. to the nasal side of the retina, and so on for other
parts.)

In cataract the functional activity of the retina, as tested by a candle,
or better, by the reflected light from a mirror, throughout the V. F., is a
question which may decide for or against an operation.

In a certain form of retinitis (pigmentosa) the concentric limitation of
the V. F. is peculiar and characteristic. Cases of this disease are often
seen with good and sometimes perfect central vision, while the V. F. is
reduced to an area not exceeding 10° or 15° in extent.

In glaucoma the V. F. is contracted, and most frequently on the nasal
side. Often it is this symptom that decides the diagnosis in a doubtful
case.

In hemianopsia (blindness in one-half of the V. F.) we often gain im-
portant information as to the locality of the intra-cranial lesion upon which
it depends, by a study of the V. F. The most frequent form is homony-
mous hemianopsia, or blindness of corresponding halves of each V. F. (the
nasal of one and the temporal of the other), and in these cases the lesion
will be on the opposite side of the brain, involving either the optic tract
or the cerebral substance further back. Grossed hemianopsia presents two
varieties — first, absence of the temporal half, and, second, absence of the
nasal half, of each eye. In the first variety the lesion involves the chiasm,
and in the second, which is very rare, the lesion is a double one, involving
each side of the chiasm or the outer side of each nerve.

In megrim, or sick headache, there are often transient attacks of blind-
ness, or interruptions in the V. F., sometimes of a zigzag form, which is
likened to a line of fortification. The cause of these phenomema is prob-
ably ischasmia of the retina. They are sometimes seen without headache
or other symptoms.

In optic neuritis interruptions in the V. F. are common. They may
be peripheric or central. The latter are called scotomata, and they are
usually indicative of less gravity than peripheral limitations, which are as
a rule followed by atrophy of the nerve.

In optic nerve atrophy defects in the V. F. are frequently seen, and
most often they begin with peripheral limitation on the temporal side.
Irregularity, such as sinuosity of outline, or scotomata, are suggestive of
an unfavourable prognosis.

Amblyopic affections usually present irregularities in the V. F. that aid
us in forming a prognosis. It may be said in general terms, that cases with
peripheral contraction are progressive, and that those with perfectly out-
lined fields, either remain stationary or improve.

A more careful examination as to the amount of vision in the various
parts of the Y. F., will probably enable us to diagnose our cases with
more accuracy, and to speak with greater positiveness about the prog-
nosis in cases which are embraced under the last three headings.

Cohen, Laryngoscopy as a Means of Diagnosis. [July

All that can at present be claimed for colour defects in the V. F., of
pathological origin, is that they are of material assistance as an aid to
diagnosis, and that they help us in rendering a prognosis, when taken in
connection with the other conditions, that go toward making up the case
in question. Peripheral limitation of the colour-field, or inability to dis-
tinguish certain or all colours, in a circumscribed area (colour scotoma)
or throughout the entire V. F., is of frequent occurrence in optic neuritis,
in optic nerve atrophy, and in amblyopia. And the same rules that
govern defects in the ordinary V. F., apply to abnormal colour perception.
Red is the colour that usually suffers first, and green usually coincidently
or next, and finally blue.

A central scotoma for red, complete or partial, accompanied with more
or less marked intra-ocular appearances, is considered by many as being
almost pathognomonic of tobacco amblyopia. In most of these cases
alcohol will also have been used, and a low grade of optic neuritis can
usually be detected.

Qm'nia, when given in large doses, sometimes causes narrowing of the
V. F. and limitation of the colour-field or colour-blindness, and may cause
total amaurosis.

The same effects are ascribed to salicin. The functions slowly return
under the influence of time and proper treatment.
New York, December, 1882.

Article V.

Some Points in relation to the Diagnostic Significance of Immo
bility of one vocal band ; with especial reference to anchylosis
of the Crico- Arytenoid Articulation and Aneurism of the Arch
of the Aorta: with Six Illustrative Cases.1 By Solomon Solis
Cohen, A.M., M.D., Demonstrator of Pathology and Microscopy in the
Philadelphia Polyclinic and College for Graduates in Medicine.

The object of this paper is twofold: 1st, to show that laryngoscopy
may sometimes be the sole, or most efficient means of diagnosis in affec-
tions located exterior to the larynx ; and 2d, to point out that a liability
to error might often be incurred, were we to place too exclusive a reliance
upon the objective symptoms, as presented by the image seen in the laryn-
goscopy mirror.

These points, however, will not be treated of in extenso, or with any
attempt at completeness ; but a single phase of the subject will be illus-

1 Presented as an Inaugural Thesis to the Faculty of Jefferson Medical College.
Session 1882-1883.

1883.] Cohen, Laryngoscopy as a Means of Diagnosis.

trated by a group of cases not heretofore reported in this connection.
These cases, while differing in aspects to be mentioned later, agreed very
closely in the character of the picture seen upon laryngoscopic inspection ;
the principal and only well-marked feature of which was immobility of
one vocal band.

As is well known, immobility of a vocal band is the result of one of two
conditions : 1st, mechanical impediment to the movement of the arytenoid
cartilage ; 2d, want of power in the muscles acting upon that cartilage.

Excluding such obvious causes as the presence of a tumour or of a
foreign body, excessive thickening of the inter-arytenoid fold, etc. ; me-
chanical difficulty may arise from anchylosis (either true or false) of the
crico-arytenoid joint ; from destruction, more or less complete, of the
articulation, or of the arytenoid cartilage ; or from luxation of the aryte-
noid cartilage ; of all of which conditions, instances have been reported.

Loss of muscular power may be either myopathic or neuropathic in
origin. If defective innervation be the cause of the impairment,, this con-
dition may be due to disease or injury affecting the nervous system, or
may be merely a secondary effect, resulting mechanically from pressure
exerted upon a nerve trunk by a consolidated lung, an aneurism, a tumour,
or an enlarged gland, etc. The seat of the lesion or pressure,, may be
central, or at some portion of the course of the fibres transmitting motor
impressions ; whether these fibres be known in that particular situation
under the name of spinal accessory, pneumogastric, or recurrent laryngeal.

Poisoning by lead, and perhaps other toxic agents, may also be the
cause of vocal paralyses, and without being able to indicate the exact
modus operandi in such instances, we may, in passing, mention them as
among the possibilities to be considered.

Some of the conditions here indicated will not be again alluded to, as
they would give rise to manifestations beyond the larynx sufficiently
prominent to attract attention, and sufficiently characteristic to render the
diagnosis comparatively easy. Nop is it purposed to enter upon the
characteristics by which different forms of muscular and nervous paralyses
are differentiated ; these being, for the most part, sufficiently obvious upon
consideration of* the anatomy and physiology of the parts. In order to
restrict this paper within reasonable limits, attention will be directed only
to the means by which, in certain cases, a conclusion may be reached as
to what may be termed the gross character of the lesion ; the finer details
being considered merely in so far as they may have a direct bearing on
this subject.

"With this object in view, it seems appropriate to introduce at this junc-
ture, the histories of the cases from which our deductions will be drawn.

Case I. Anchylosis of the Left Crico-Aryt noid Articulation ; proba-
bly due to Extension of the Inflam matory Process in a case of Chronic La-
ryngitis C. S. G., aet. 23, clerk, applied to Dr. J. ISolis Cohen May 27,

Cohen, Laryngoscopy as a Means of Diagnosis. [July

1881, giving the following history : He had enjoyed fairly good health
until about sixteen years old. At that time, he contracted from expo-
sure, what was probably a naso-pharyngeal catarrh, the inflammation in-
volving, also, the Eustachian tubes ; for he states that he experienced in
addition to nasal symptoms, a disagreeable sense of fulness in both ears,
and that the physician under whose care he then placed himself, treated
him exclusively for ear-trouble, but without affording relief.

As frequently happens in such cases, the larynx became slowly in-
volved ; and in the spring of 1879, he first noticed a huskiness in his
voice. This huskiness gradually increased, becoming attended with dys-
phonia, until considerable and painful effort was necessary in order to
carry on conversation ; and in the fall of 1880, he became completely
aphonic. His general health having greatly deteriorated, he made a trip
to Texas, from which he derived considerable benefit ; his voice sharing
in the general improvement.

His condition on applying to Dr. Cohen, was as follows : His voice
was hoarse and rough, but distinct and easily heard. It was deficient in
tone and power, and any extended use of it would cause the throat to
feel tired and sore, while respiration would become slightly embarrassed.
When, however, the nasal passages seemed to be clogged with mucus, so
that respiration was less free than usual, the voice sounded clearer and
stronger, and the throat did not tire so quickly. Owing to his nasal ca-
tarrh, the sense of smell was slightly impaired, and nasal respiration
always somewhat obstructed. Fulness in the ears, unattended with pain,
was a not infrequent symptom. There was no cough, and deglutition
was not painful. Appetite was good, and nutrition seemed to be well
carried on. The muscles of the right side of the neck and face appeared
to have undergone hypertrophic development ; probably from the in-
creased action necessary to bring the vocal bands into approximation.

On laryngoscopic examination, the mucous membrane of the larynx
presented evidences of chronic inflammation, and there was seen to be
moderate tumefaction of the ary-epiglottic folds, ventricular bands and
arytenoid eminences. The right ary-epiglottic fold was extremely tense.
The left ventricular band exhibited a peculiar fold or knuckle, posteriorly,
which became more marked on phonation ; when it was also seen that
the left vocal band remained immobile in abduction, the right band

crossing the median line, its upper surface being
Fig. 1- on a plane almost inappreciably lower than that

of the left band ; while the right arytenoid
cartilage wTas swung to the inside and in front
of the left arytenoid cartilage. This appear-
ance, almost as difficult to depict as to ex-
plain, is shown in the accompanying drawing,
Fig. 1 ; for which, the writer is indebted to
the artistic skill of an undergraduate of the
College, Mr. Max. J. Stern.

No sign of cardiac or pulmonary lesion, of
aneurism or intra-thoracic tumour, could be
discovered, nor were any enlarged glands found
in the neck. The urine was examined with
negative results. Attempts to move the left
arytenoid cartilage by direct pressure were unsuccessful ; and while the
catarrhal condition yielded to appropriate remedies, prolonged treatment

1883.] Cohen, Laryngoscopy as a Means of Diagnosis.

by means of both galvanic and faradic currents, as well as the internal
administration of strychnine, failed to restore in the slightest degree the
mobility of the affected vocal band.

Case II. Anchylosis of the Right Crico- Arytenoid Articulation, due to pro-
longed enforced inaction, consequent upon Fibroma of the Right Vocal Band.
Reported by Dr. J. Solis Cohen. — W. B., set. 26, shoemaker, applied to Dr.
Cohen May 1, 1867, to be treated for loss of voice of more than two years' du-
ration. Laryngoscopic inspection having revealed the existence of a neoplasm
occupying the entire length of the right vocal band, thyrotomy was performed,
and the growth was removed. The patient's voice, though improved by the
operation, was still aphonic. On laryngoscopic examination, the band from
which the tumour had been removed was seen to be immobile in abduction, and
slightly above the level of that of the opposite side. A peculiar angular fold
which had been noticed at the posterior portion of the free border of the right
ventricular band, and had been attributed to its being pushed out of shape by the
tumour, was seen to be persistent. No effect being produced by treatment, Dr.
Cohen concluded that during the development of the neoplasm, the cricoaryte-
noid articulation had become anchylosed. This opinion was verified by Dr. R.
J. Levis, who had assisted at the operation, and who now, at Dr. Cohen's re-
quest, placed his forefinger, " which is a long one," upon the arytenoid cartil-
ages, and succeeded in moving that of the left side, while that of the right side
remained fixed. — Med. Record, July 1, 1869.

Case III. Aneurism of the Arch of the Aorta compressing the Left
Pneumo gastric and Recurrent Laryngeal Nerves ; Left Vocal Band
immobile in Abduction. Death from Rupture of the Sac- — A. J., set. 60,
sailor, applied to the Throat Clinic of the Jefferson Medical College
Hospital, July 1, 1881, for the relief of hoarseness and dyspncea which
had persisted since the previous October, in association with violent
attacks of coughing. He attributed the origin of his trouble to exposure,
resulting in a severe cold. There was a history of a venereal sore con-
tracted forty years previously, but there had never been any secondary
symptoms in evidence of syphilitic infection. He had several times suf-
fered with rheumatism, a severe attack in 1864 lasting for two months.
He had followed the sea for forty years without other sickness.

Llis breathing was stridulous, especially during sleep ; dyspnoea was
marked, increasing in the recumbent position, so that he was compelled
to sleep propped up with pillows. There was severe pain on the left side
of the chest, front, and back, increasing at night. At times he com-
plained of pain in the left hip and in the lower third of the left thigh.
He had lost flesh, being reduced from 182 pounds to 150 pounds. His
appetite was poor, but he had been a dyspeptic for years. Any attempt
at laryngoscopic examination provoked an attack of coughing and dysp-
ncea, so severe as to completely prostrate him ; thus leading to suspicion
of paralysis of the posterior crico-arytenoid muscles. After some days,
however, he became more tolerant, and with delicate manipulation it was
possible to conduct a rapid examination. It was thus gradually ascer-
tained that the left vocal band was immobile in abduction, while the
right vocal band performed its movements in a somewhat jerky and spas-
modic manner. On inspection of the chest, a prominence was noticed in
the sternal region, extending from the clavicle to the level of the fourth
sterno-chondral articulation, most marked at the level of the third sterno-
chondral articulation. No satisfactory information could be obtained,
however, as to the length of time for which this condition had existed, or
as to whether or not it had been congenital. Percussion elicited slight

Cohen, Laryngoscopy as a Means of Diagnosis. [July

dulness anteriorly on both sides as far down as the fourth rib. On aus-
cultation tubular breathing was heard in the right infra-clavicular region.
The expiratory sounds were very feeble on both sides.

The heart sounds were normal, but the second sound was distinctly
heard two and one-half inches to the right of the sternum. No difference
was discernible between the radial pulses or between the pupils. Exami-
nation of the urine gave negative results.

This case was presented to the Philadelphia Laryngological Association,
and held by competent observers to be one of crico-arytenoid anchylosis.
The extreme irritability of the larynx prevented a successful attempt to
verify or disprove this diagnosis by the application of direct pressure.

Although it was endeavoured to keep this patient under constant obser-
vation, his unwillingness to enter the hospital on the one hand, and the
irregularity of his attendance upon the clinic — caused by the relief afforded
by palliative treatment — on the other hand, rendered it impossible to do
so. After an unusually prolonged absence, an attempt to trace his where-
abouts revealed the fact that his death had occurred during a profuse
hemorrhage, about ten days previously (August, 1882). The physician
who was called in the emergency, reports that there was spitting of blood
for two days, after which came the fatal hemorrhage, by him suspected
to be of pulmonary origin. Post-mortem examination was not permitted.

Case IV. Aneurism of the Arch of the Aorta compressing the Left
Recurrent Laryngeal Nerve ; Left Vocal Band Immobile in Abduction.
— W. M. K., aet. 57, farmer, presented himself September 13, 1882, at
the Throat Clinic of the Jefferson Medical College Hospital ; and on the
following day was made the subject of a clinical lecture to the class, by
Dr. J. Solis Cohen.

In May, 1881, this patient became hoarse while at work, after profuse
perspiration. In the last four weeks dyspnoea had developed. There
was no cough, and no difficulty in deglutition. The patient's general
health and family record were good. Syphilis was at first denied, but
upon cross-questioning a history of constitutional symptoms was obtained.
He had also suffered a number of years ago with rheumatism.

Laryngoscopic examination revealed the left vocal band immobile in
abduction. This led to the suspicion of aneurism of the arch of the aorta,
and upon physical exploration of the chest the suspicion became a cer-
tainty ; thrill and bruit being unmistakably present. The pulse was also
characteristic of aneurism. The patient was placed in one of the wards
of the hospital under the care of Dr. Cohen, and . as the result of appro-
priate treatment rapidly improved. Dr. Charles Meigs Wilson, the resi-
dent physician, reports that when he was discharged at his own request,
after six weeks' confinement to bed, the dyspnoea had disappeared, the
voice was stronger, the equality of the pulses restored, and the signs in
the chest scarcely perceptible.

Case V. Aneurism of the Arch of the Aorta, compressing the Left Pneumo-
gastric and Recurrent Laryngeal Nerves; Cadaveric position of the Left Vocal
Band; Sudden Death from Asphyxia; Autopsy. Reported by Dr. C. E. Bean. —
R. C, ast. 42, engineer, presented himself Sept. 29, 1880, at the Throat Clinic
of the Jefferson Medical College Hospital, under the charge of Dr. J. Solis
Cohen. In December, 1878, the boiler of which he had care exploded, and
after working for several hours in the heat and steam, he became chilled upon
exposure to the night air. Two days later his voice became hoarse, getting
gradually worse, until at the end of a week there was complete aphonia ; but
at no time was there any pain or soreness in the throat. Dysphagia soon became

1883.] Cohen, Laryngoscopy as a Means of Diagnosis.

a prominent symptom. About a week after the explosion lie began to cough,
expectorating thick frothy mucus. Three months later he first experienced a
sense of fulness in the upper part of the chest, just behind the sternum. Respiration
was not materially interfered with. The cough, though occasionally wheezing,
had assumed a ringing metallic character. Laryngoscopic examination showed
fixation of the left vocal band in the cadaveric position.

Thrills were detected below the clavicles, synchronous with the pulse, but
these signs disappeared the day after the patient was put to bed. There was no
perceptible difference between the radial pulses. The heart sounds were normal.
The left pupil was markedly contracted, but this had been the case as far back
as the patient's recollection extended. A diagnosis of aneurism of the arch of
the aorta was made, but its correctness was disputed by several experienced and
qualified observers who made careful examination of the case.

The patient died suddenly Nov. 13, "gasping for breath, unconscious, face
and neck very much congested," despite the performance of tracheotomy by the
resident physician of the hospital, who reports the case, and who had been hastily
summoned in the emergency.

The following is the report of the conditions found on post-mortem exami-
nation : —

"The apex of the heart corresponded to the left sixth intercostal space, one inch
beyond the line of the nipple. The upper part of the anterior mediastinal space
was broadened and filled with a fluctuating mass, commencing at the upper
border of the pericardium and extending to the sternal notch. The heart and
lungs with the descending aorta were removed en masse. It was found that the
aorta was dilated into a large sac, commencing just above the valves and involv-
ing the arch to a point beyond the left subclavian artery. . The sac of the aneu-
rism was tightly adherent on the left side of the second and third dorsal vertebras.
On removing the mass, the wall of tlie sac was found to have disappeared at
this point. The aneurism had deflected the lower portion of the trachea strongly
to the right, and pressed mostly on the root of the right lung. On looking into
the trachea it was seen that its calibre was nearly closed by pressure. Examin-
ing the interior of the aneurismal sac, the lower tracheal rings partly calcified
had been laid bare and eroded by the pulsation. They protruded with the
aneurismal cavity. The left pneumogastric nerve was found running over the
aneurism, and had been evidently much pressed upon. The right nerve was less
involved. A large ante-mortem clot was discovered in the sac." — Louisville
Med. News, Jan. 22, 1881.

Case VI. Aneurism of the Arch of the Aorta compressing the Left Recurrent
Laryngeal Nerve ; Left Vocal Band immobile in Abduction. Reported by Dr.
C. E. Bean. — J. S., a?t. 70, weaver, applied to Dr. J. Solis Cohen May 17,
1882, for the relief of hoarseness. Sept. 17, 1879, after lifting heavy rolls of
carpet, he felt "a peculiar heavy stroke of the heart, and a sense of extreme
weakness, so that he 'came near fainting.'" This soon passed away. One
week later, two similar attacks occurred. Soon after this hoarseness set in, be-
coming gradually worse. At the time of examination there was slight dysphonia,
and the voice was a falsetto. For several' months, even during warm weather,
the patient's feet had been cold, but, with this exception, his general condition
was good.

Laryngoscopic examination showed the left vocal band immobile in abduction.

Inspection of the chest revealed nothing abnormal. On auscultation, a blow-
ing sound was heard in the second intercostal space, ^ inch to f inch to the left
of the sternum. This sound was synchronous with the ventricular systole.
Inspiration was found to be shrill at the second sterno-chondral articulation, and
percussion elicited marked dulness over the same region. Palpation failed to
discover thrills or pulsation.

The pulse was 7.0 and feeble, that of the left side being scarcely perceptible,
and lagging one-fourth of a beat behind that of the right side. There was no
difference between the pupils. A considerable quantity of sugar was found in
the urine.

Marked improvement took place under treatment directed against the condi-
tion of aneurism, but the patient became impatient of confinement to bed, and,

Cohen, Laryngoscopy as a Means of Diagnosis.

[July

contrary to advice, resumed his usual occupations. At last accounts he was still
living, and, except for slight hoarseness, perfectly satisfied with his condition. —
Med. and Surg. Reporter, June 10, 1882.

^In reviewing the cases presented in the foregoing pages, there are a
few points of special interest to be noticed in each, which it may be well
to consider in logical rather than numerical order.

Case II. demonstrates the possibility of anchylosis taking place in the
crico-arytenoid joint simply from prolonged inaction. The history, the
absence of any other local or systemic disturbance, the failure to respond
to treatment, and, finally, the expert mentum cruris of the application of
direct pressure, all place the diagnosis beyond doubt.

Case I. The history of pre-existing, long-continued chronic laryngitis
rendered two views within the bounds of possibility: 1st. Myopathic
paresis of the crico-arytenoideus lateralis, resulting from extension of the
inflammatory process ; 2d. Anchylosis of the crico-arytenoid articulation
from a similar cause. Apart from the greater improbability of the former
opinion, the failure to respond to treatment would be against it; while, as
in Case II., the diagnosis seems to be fully established by the exjjerimentum
cruris.

In both these cases, there are certain points connected with the laryngo-
scopic image deserving of attention. The vocal band of the affected side
occupied a higher level than that of the other side. Can this be explained
upon the supposition of inflammatory deposit within the joint, and is it to
be considered pathognomonic ? This would seem well worthy of observa-
tion in future studies of this rare affection. Furthermore, the peculiar
fold or knuckle in the ventricular band of the affected side, occurring in
cases so far removed in time, and owing to such different causes, would
appear to be more than a mere coincidence.

Still another symptom, not mentioned in the resume of Case II. because
not bearing on the subject then in hand, yet shared by both of the cases
now under discussion, is of interest in connection with the general topic
of mechanical impediment to the movement of the vocal bands.

Previous to the removal of the tumour from his right vocal band, the
patient was compelled to draw his head and neck well down toward his
right shoulder in order to produce his aphonic whisper to the best advan-
tage ; though subsequent to the operation this was no longer necessary.
In Case I. the left vocal band was immobile, and the patient spoke with
his head slightly inclined downward and to the left ; the muscles of the
right side of the face and neck, as previously stated, being noticeably
hypertrophied. This point also appears worthy of remembrance in future
observations.

Case V. possesses a high degree of interest, inasmuch as the existence
of an aneurism of the arch of the aorta was suggested to a laryngoscopist
in a diagnosis by exclusion, of the condition leading to what is usually

1883.] Cohen, Laryngoscopy as a Means of Diagnosis.

termed unilateral vocal paralysis. While the rational symptoms were
confirmatory of this opinion, the entire absence of the usual physical signs
of aneurism caused experts in physical diagnosis, unfamiliar with laryn-
goscopy, to doubt its correctness. This case alone fully exemplifies the
two texts of this paper ; for by relying solely upon the laryngoscopic image
the diagnosis would have been neurotic paralysis, while failure to examine
the larynx, or to give due weight to its testimony, would have rendered it
unlikely for aneurism to have been surmised in the absence of the phe-
nomena usually associated with that affection; there being neither tumour,
bruit, nor thrill.

In Case VI. again we have apparent laryngeal disease leading to the
discovery of an aneurism which might otherwise not have been detected.
The probable small size of the sac, or its favourable situation, prevented
compression of the trachea or oesophagus. The pneumogastric trunk not
being subject to pressure, another possible cause of cough and dyspnoea
was eliminated ; hence, the only symptoms attracting the patient's atten-
tion were the persistent hoarseness, and the deficient peripheral circulation
— the latter condition, however, being easily attributable to old age. The
presence of sugar in the urine, probably from reflex irritation of the pneu-
mogastric nucleus in the floor of the. fourth ventricle, was confirmatory of
the diagnosis ; but, as shown by other cases, this sign is not invariably
present. The only one of the ordinary physical signs of aneurism exhib-
ited by this case, was the blowing sound in the left second intercostal
space.

Case III. is so obscure that in the absence of an autopsy it is impossible
to definitely decide its true nature ; nor can any one hypothesis explain it
fully. Disregarding for the purposes of this paper any possible complica-
tion not directly bearing upon the lesion manifested by the laryngeal
symptoms, the manner of death would point to aortic aneurism; and upon
this supposition the dyspnoea can be explained as the result of com-
pression of the trachea, while the tubular breathing in the right infra-
clavicular region may be accounted for by pressure exerted upon the air-
vesicles in that situation. To the sternal bulging no weight can be
attached. The history of rheumatism, while it favoured somewhat the
view of aneurism, might likewise, especially in connection with the
chronic laryngitis following subacute laryngitis due to direct exposure,
have strengthened the view of anchylosis ; while evidences of nervous
disturbance might have justified the reference of cough and dyspnoea to
disease of the pneumogastric trunk. The intensity of these symptoms at
first, and their amelioration under medication, point at least to partial
nervous origin ; probably a secondary effect of the pressure of the aneurism
upon the nerves, exactly similar to the immobility of the vocal band. The
fact that the position in which the band was fixed was not cadaveric, but
that of abduction, is of interest, illustrating (as do Cases IV. and VI.)

Cohen, Laryngoscopy as a Means of Diagnosis.

[July

the greater liability to impairment of the adductor, over the abductor,
filaments of the recurrent laryngeal nerve; a clinical point to which atten-
tion has been prominently directed of late years. An intra-thoracic neo-
plasm might have produced the same mechanical effects as an aneurism ;
but it is difficult to imagine a morbid growth of sufficient size occupying
just this situation, and giving rise to no definite manifestations elsewhere
in the economy.

In Case IV., also, we have aneurism detected by means of the laryngo-
scope ; the patient complaining merely of hoarseness and slight dyspnoea.
But the evidences of aneurism were so distinct, that the diagnosis pre-
sented no difficulty, and might have been made without laryngoscopy
assistance.

In three of these cases of aneurism, it is interesting to note that expo-
sure very likely to lead to ordinary subacute laryngitis preceded the laryn-
geal symptoms, thus causing the patients to imagine that they had simply
" caught a bad cold ;" and well calculated to mislead the physician ; espe-
cially had the larynx not been examined.

The question arises, in this connection, whether the exposure and
resulting inflammation precipitated the laryngeal complications of the
aneurism, or whether the condition of paralysis had not been pre-existent,
thus rendering recovery from the inflammatory hoarseness protracted, if
not impossible.

In two cases we have history of preceding rheumatism ; in one, of
syphilis as well.

Finally, to generalize from all the cases herewith presented, generaliza-
tions which are warranted by the recorded observations of several authors,
we may conclude : —

I. That whenever the left vocal band is immobile in abduction, or in
the cadaveric position (positions in which the patency of the glottis is not
interfered with), and there is cough or dyspnoea (or both), without car-
diac or pulmonary lesion to account for these symptoms, we are justified
in suspecting aneurism of the aortic arch ; and difficult deglutition will
be almost certainly confirmatory of the diagnosis, notwithstanding the
absence of tumour, pulsation, thrill, and bruit. The only, and exceedingly
improbable source of error, would be intra-thoracic neoplasm.

II. That anchylosis of the crico-arytenoid articulation may fairly be
suspected in cases of immobility of one vocal band, not referable to
mechanical interference with the transmission of nervous force ; unaccom-
panied with evidence of central or local nervous disease ; and in which
failure to respond to appropriate treatment will warrant us in excluding
muscular atrophy. But the diagnosis can be finally established only by
the application of direct pressure to the affected arytenoid cartilage.

III. That whenever one vocal band is immobile in the cadaveric
position or in abduction, and there are no other signs or symptoms to

1883.]

Burr, Primary Monomania.

assist the diagnosis, anchylosis being eliminated, we should not be satis-
fied with a diagnosis of neuropathic paralysis; but should keep the patient
under observation, with a view to detecting the earliest manifestation of
aneurism, consolidated lung, or other mechanical cause for the impaired
innervation.

Note Since the above was written, a case has presented itself (Jan.

29, 1883) at the Throat Clinic of the College Hospital, in which an aneu-
rism of the innominate artery, involving as well the first portion of the right
subclavian artery, around which latter winds the right recurrent laryngeal
nerve, has, by compressing that nerve, produced cadaveric paralysis of the
right vocal band. The voice of this patient has a peculiar shrill tone,
and in the act of phonation he carries his head downward and well over
to the left. There is a pulsatile tumour just behind the sterno-clavicular
articulation, extending laterally about two inches from the median line,
rising about one and a quarter inches above the clavicle, and projecting
about one-quarter of an inch.

Article VI.

A Case of Primary Monomania (Prim'are Verriicktheit). By C. B. Burr,
M.D., Asst. Physician to the Eastern Michigan Asylum, Pontiac.

The circumstances connected with the trial of Guiteau brought promi-
nently to notice a peculiar form of insanity, the so-called primary mono-
mania. In view of the professional interest attaching to this variety of
mental disease, the following case is reported : —

K., age 40, was born in New York. His father was of Irish birth, a
drunkard, and abusive in his family. His mother was of English descent,
but a native of New Jersey ; one of a family that is said by the patient to
have inherited upward of seventy millions of dollars (?) which cannot be
recovered. The early life of the boy was one of hardship, privation, and
suffering, and his surroundings were such as to leave enduring unpleasant
impressions in his mind. Through the neglect and cruelty of the father
the family was separated early. He at the age of eight years was bound
out to a mechanic with whom he remained until he was fifteen. After
this period he worked at different trades, but showed no capacity for in-
struction, could not apply himself, and failed to succeed. He hired out to
one employer and another, but his " mind was roaming all over the world ;"
he was restless, unsettled, and governed by impulses. In this mental
state he made his way to New York, and shipping on a sailing vessel
made a six weeks' voyage. He ascended the Mississippi from New Orleans,

Burr, Primary Monomania.

[July

came across the intervening States to Michigan, and took up his residence
with an uncle in Grand Haven. There he remained for one year ; for the
next four he resided in different parts of Connecticut and New York. Dur-
ing this latter period he received his only schooling, studying the ordinary
branches of reading, spelling, and arithmetic.

At the age of twenty-one he was living in Jackson, Mich. Here, li-
near as can be ascertained from his own account, mental alienation became
pronounced. A fixed light appeared to him " coming from the morning
and evening stars, descending in the shape of a heart." He was at first
dazed and bewildered, and at a loss to account for this strange manifesta*
tion ; then he set about diligently to discover an explanation. He scru-
tinized his own condition carefully, was critical and morbidly suspicious
of others. A recurrence of the visual hallucination rendered him still
more thoughtful. He experienced strange sensations and felt a conscious-
ness of being no longer his former self. "What could produce such a change ?
He could account for it only on the supposition that a miracle was being
wrought, and it dawned upon him at once that he was " inspired."

The most trifling circumstances confirmed him in this view. The mere
mention of his name by one in conversation had a peculiar significance ;
a look, a glance, or a casual inquiry impressed him deeply, and he drew
absurd conclusions from the most innocent remarks. Conceiving himself
of necessity an object of great interest, he imagined his affairs were the
topic of general conversation. The sight of persons talking together in
the street aroused in his mind the belief that a conspiracy was forming
against him, a look or gesture being sufficient to convey such important
intelligence. He heard his name repeatedly mentioned by men of promi-
nence, and concluded that if he were not the object of their active enmity
at least there were special reasons why they should be talking and think-
ing about him.

Casting about for an explanation of imaginary slights, it was revealed
to him that his secret liking for a young lady, the daughter of a wealthy
farmer, had been divined, and that a " campaign" was being inaugurated
to force him to leave the country. He was naturally bashful, retiring,
reserved, and ill at ease in female society, but at this period there seem
to have been several ladies whose destinies he imagined in some way in-
volved with, his own. There were none to whom he paid active court ;
indeed with many he had not even a speaking acquaintance ; but a toss of
the head, a glance, the jostling incident to a crowded place, gave him a
peculiar thrill, and caused him to understand the deep regard in wThich he
was held.

In 1861 he enlisted in the army. Here, according to his own account
contained in a pamphlet entitled " The Hero of Seven Battles,'" he was
many times the object of special interposition of Providence, having been
miraculously rescued for some great purpose. " Persecution" followed

1883.]

Burr, Primary Monomania.

him into the service. His comrades, envious of his attainments and un-
willing to see him promoted, threw obstacles in the way of his advance-
ment. Being compelled to remain in the ranks, while believing himself
fitted to hold the most responsible position in the service, he was rendered
restless and unhappy. He was importunate in his demands for promotion,
and sought from officers high in authority a recognition of his claims.
Because these were disregarded, he argued a lack of patriotism on the
part of those in command, and believed this but a part of the " conspiracy
to crush" him. These unpatriotic acts were not allowed to go unpunished.
He saw those who had reviled and scoffed at him stricken down by bullets ;
he saw officers who had refused him audience, denied his requests or
dealt harshly with him, superseded in command. He avers that the
reverses which befell General Porter and General McClellan were the
direct outcome of their unjustifiable treatment of him.

For six months after his discharge he was an inmate of the government
hospital for the insane at Washington. Upon his return home he took
(like many another crank) to literary (?) pursuits, and travelled through
Indiana with a lecture on i; War." This tour did not prove a financial
success. Rough-looking fellows " in solid columns " demanded admission
to his lectures without paying the fee, and, being indulged, showed their
gratitude by breaking up the meetings. On such occasions the orator
barely escaped with his life.

He next adopted the occupation of peddling, and in going about from
place to place was the recipient of many, to him, singular and significant
experiences. Many people at 'this time in his opinion held him a veritable
Saviour.

In obedience to a demand on the part of the people for correct informa-
tion on the subject of the war, and his own part therein, he wrote the

pamphlet alluded to : ;i The Ways of the World being a Life of . ,

the Hero of Seven Battles." This is an illiterate, disconnected, self-
laudatory composition, and was used in the probate court to substantiate
his insanity. A careful scrutiny of its pages fails to bring to light any act
■which would be accounted by a sane man especially heroic.

Eight years ago he married. He was scarcely acquainted with his wife
previous to marriage, and, owing to excessive embarrassment on his part,
the engagement was made wholly through the medium of correspondence.
Fortunately no children have been born of this union.

His reputation in his own neghbourhood is excellent. It is said 'that
few are more honest and straightforward in business matters. He is also
of good habits. He succeeded at one time in accumulating a fair property,
but did not show good judgment in managing it. He seems to "have had
expansive ideas ; at least on one occasion he placed a mortgage upon un-
encumbered real estate which was supporting him well, in order to make
additional purchases and accommodate an impecunious brother-in-law.

Burr, Primary Monomania.

[July

For many years he has been regarded peculiar, erratic, visionary, and
eccentric, if not actually insane; the character of his book and his claim
of inspiration being the main grounds upon which these judgments were
based. All had believed, however, that lunacy, if present, was of a
" harmless" type.

The immediate cause of his commitment to the asylum was the shooting
of one who had been appointed a special guardian for the purpose of
prosecuting his claim for a pension. On investigation it was discovered
that he was not entitled to government aid on the ground of mental in-
firmity, as this antedated his army service. He, however, conceived that
either negotiations for the pension were delayed by reason of the neglect
or inefficiency of his guardian, or that the money had been paid and
withheld from him. At the same time also (entertaining possibly the
vague dread which one half-conscious of insanity feels) he became fearful
that he would be sent to an asylum through the machinations of this same
man. Meeting him in the street one day, he asked him what he had done
with his pension money. The guardian replying that he had never re-
ceived any, he said, " you are trying to beat me out of it." This was
denied. He thereupon called him " a liar," and shot him with a revolver
he had long been accustomed to carry. He was in debt to his guardian
for borrowed money. It is impossible to say whether this fact furnished
an additional motive for the commission of the crime.

After the shooting he fled to avoid arrest, travelling mainly at night.
To obtain food he was occasionally necessitated to call at farm-houses.
To account for his presence at such places at unseasonable hours, he gave
out that he was searching for a stolen horse, or invented other plausible
excuses. Hearing that his shot had not proved fatal, he returned volun-
tarily, gave himself up, and was lodged in jail. There he was pleasant
and composed, but inclined to talk of inspiration, and declaim against his
associates, by whose presence he thought himself very much degraded-
He expressed no actual remorse for the shooting, but said if he ever
lived to get home he would injure no man again.

It now came to light that he had long contemplated murder for the
righting of his wrongs. He had twice visited his guardian's house with
the intention of " forcing him to a settlement" of his claims at all hazards,
and had carried arms to be used in case the emergency demanded. With
a loaded shot-gun he also called at the office of the judge of probate, but
the outer door, moved by the wind, slammed in his face, and he turned
away filled with superstitious dread, not daring to enter.

His condition on admission was as follows : Of medium height ; personal
appearance neat; temperature and circulation normal; respiratory murmur
harsh at the apices of the lungs.; in good flesh, but troubled with a cough ;
had a coated tongue, and suffered slightly from constipation ; pupils di-
lated ; vision in right eye defective ; head small and misshapen ; there

1883.]

Burr, Primary Monomania.

were numerous scars on his person, one being on the forehead ; expression
of countenance attentive, watchful, and somewhat suspicious ; replies
prompt, but guarded, and he seemed distrustful; coherency somewhat im-
paired; memory good ; general character of conversation rambling, and
chiefly relating to delusions ; questions as to his business, property, or
current events answered rationally. He was very much pleased by any
expression of interest in his delusions, and did not hesitate to lay claim to
inspiration ; was very desirous of enlisting some great man in the work to
which he himself had been assigned.

His expression of countenance was a variable one. In speaking of his
delusions, his face lighted up and he exhibited considerable animation.
There was a settled look of suspicion, however, and in conversation he
was confidential. He gave furtive glances over his shoulder from time to
time as if fearing to be overheard. His mental characteristics have been
and continue as follows : He is quiet and free from irritability ; is indus-
trious, helpful, and considerate. To feeble patients he is kind and oblig-
ing. He is much given to writing, and has composed a large amount of
manuscript, which he calls a history of his life. Its style is grandiloquent
and egotistic.

He prefaces a biographical sketch with the statement that his life is
now in great demand, and asks why he is expected to write the history of
so great a life, adding that he never, as yet, held any public office or killed
anybody. His answer is that " the carricteristic nature of my life is and
has bin so queer from any other man's life, that is the reason why it is
in such great demand." He relates in this "paper" how he made appli-
cation for a pension on the ground of insanity, and how he advocated the
appointment of a guardian. He fully believes himself inspired, and inter-
lards such expressions as these, " I must not write so great a paper as this
will be, without mentioning God the ruler of the universe, his gifts to me,
and yet I am satisfide theire is something great in store for me yet." " A
foreworning of enemies in my dreams is one of god's gifts to me, so under-
stand me I know to whome is my friends by my Dreams." He believes
that he has seen God, having had in the dead of night the impression of a
" bright light" and " an eye wide open" resting on him. He believes the
physicians are able to read his mind and can "look right into" his brain.

The hallucination in respect to the " bright light descending in the
shape of a heart" persists. This is now seen in connection with any
luminous body, is with him almost constantly, and, to use his own expres-
sion, 44 shines on," leading him to the belief that there is for him 44 some
great thing in store in the future."

He has not an exalted religious sentiment. He plays games and enjoys
amusements, does not hold himself aloof from others, is not given to cant,
does not read his Bible excessively, is free from hypocrisy, and while lay-
ing claim to inspiration, does not assert his views in an offensive way,
No. CLXXI July 1388. 7

i)8

Burr, Primary Monomania.

[July

and is tolerant of the opinions of others. He is comparatively free from
personal vanity, and docs not care for ostentatious display. He has an
appreciation of the conditions of other patients, and is considerate to all.
He is self-controlled and forgiving. His sympathies are readily enlisted.
He shows no tendency to do impulsive acts, and preserves composure even
under provocation. He cherishes the belief that a great work was done
in his attempt upon the life of his guardian. He has not once expressed
remorse for the deed, but has said lie was glad the wound was not mortal.

At present he is as comfortable in all probability as at any time during
the past twenty years. No radical improvement in his mental symptoms
has occurred, but his delusions are not especially active. There seems
little prospect of future benefit from treatment. He would be able to per-
form regular physical labour, control himself under the ordinary emergen-
cies of life and support himself aud wife, but a serious obstacle stands in
the way of his discharge. Previous to his assault he was considered a
harmless, good-natured lunatic, whom no one need fear. This homicidal
act has changed the current of sentiment among his former neighbours, and
they no longer desire his presence at home. The harmless person " sane
on all subjects but one," is transformed into a homicidal lunatic, menacing
the safety of society. Is it not time that the medical profession lent its
aid to eradicating the prevalent and pernicious belief, that a condition
of sanity " on all subjects but one" can exist, and taught instead the
tyranny of a dominant delusion ? This patient struggled against doing so
terrible a deed even after his mind was made up as to its necessity. His
struggle was unavailing. Twice he visited his guardian with the inten-
tion of doing him injury, but was deterred through cowardice. Finally
his delusion obtained the mastery, and the impulse to remove a fancied
enemy could no longer be resisted.

This is but one of many instances where persons regarded "harmlessly
insane" have suddenly developed criminal instincts. Such exist in every
community, are permitted to exercise the rights of citizenship, to marry
and beget children. Is it strange that newspapers teem with accounts of
homicide, arson, and outrage committed by this irresponsible class?

The preceding case illustrates a form of disease described by German
writers under the name primare Verrucktheit. This malady occurs in
those of neurotic organization and originally feeble mental capacity ; is in
fact an expression of such defect.

These persons " grow up to be insane." The starting point of disease
in the case of K. seems to have been the period of pubescence : it is, at all
events, difficult to believe that his restlessness, tendency to wander, and
inaptitude for learning, were not indicative of a morbid change in the ner-
vous system at this important period of life. While the additional fact
that he received an injury to the head at the age of sixteen should not be
overlooked as possibly favouring mental degeneration.

1883.] Burr, Primary Monomania. 99

In respect to the form of disease under consideration, Krafft-rCbing
speaks as follows: —

" 1. It is a form of disease found almost exclusively among those whose brains
are encumbered (belastet), generally through hereditary taint.

" 2. Delusions whose primary, primordial significance is evident through the
absence of any emotional basis, or any reflection as to their origin, constitute the
nucleus of the disease.

"3. The disease has'a fixed deep constitutional character. It does not lead to
the destruction of the psychical mechanism, to dementia, but rather leaves the
apparatus of logical thought intact."

The following comparison is made by the same author between the de-
lusions of melancholia and those of primare Verriicktheit. He says

"The insane ideas may here be substantially the same, but they originate dif-
ferently. The monomaniac does not know how it happens that he is persecuted,
he does not deserve it. Gradually and in a logical manner he arrives at the con-
clusion that he is the victim of a conspiracy. The sufferer from melancholia
knows only too well why he is persecuted, he hastens to meet a shameful death.
He deserves death for he is a bad fellow. These delusions are secondary products
of emotional states. They proceed from and are grounded in a diminished self-
respect."

As many patients of the Verriicktheit class are addicted to the habit of
masturbation, and present the characteristics of insanity from this vice, it
seems important to inquire in what respect the two types of disease differ.
I believe their main point of divergence to be an absence in the former
class of the tendency to irritable dementia, which is so marked a charac-
teristic of the insanity of masturbation. In the case of K. there is also a
lack of the moral perversion which is so constantly associated with this
form of disease.

It requires but a cursory review of the foregoing case to develop the points
of resemblance it bears to that of Gaiteau. Disregarding the moral traits
of these two individuals, their cases are strikingly similar.

Each possessed a neurotic organization.

Each committed a sudden and premeditated homicidal act with an osten-
sible motive.

Each was deterred on two occasions from carrying a preformed plan
for hilling into execution.

Each took measures for personal safety after the commission of the
crime.

Each laid claim, to inspiration.

Each pleaded insanity, the one to escape punishment, the other to obtain
a pension.

Both ivere intensely egotistic, had an exaggerated sense of their own
importance, wrote profusely, and had followed unsuccessfully the profes-
sion of lecturing.

Both were visionary and expansive, and showed a lack of good business
judgment.

Each became erratic and perverted at an early age.

100

Burr, Primary Monomania.

[July

In neither case were the higher mental faculties much below the normal
standard for the individual ; each reasoned logically though from false and
inadequate premises.

Their points of dissimilarity arise almost wholly from the separate
degrees of mental development which the individuals enjoyed, and the
circumstances attending their education and training.

In contradiction of the oft-repeated assertion that the execution of an
insane criminal now and then has a deterrent effect upon others of like
propensities, the case of K. may well be cited, inasmuch as his homicidal
assault was made less than five months after the hanging of the murderer
of the President, and in face of the strong popular sentiment against the
so-called "cranks" and lawless fanatics.

There are. few more striking illustrations of the impotency of moral and
legal measures to restrain or control a morbid impulse.

Since the preparation of the above manuscript certain revelations have
been made by a fellow-patient respecting K.'s designs. It seems that
becoming restive under detention he has contemplated effecting his release
by taking the life of the superintendent of the asylum. He procured and
concealed in his stocking a sharp-pointed steel husking-pin and laid a plan
for the murder. Unless he was previously discharged this was to take
place on or after the first day of April, at which time his conscience, to
use his own expression, "would be clear." It was communicated to him
several weeks before in a dream that the superintendent was conspiring
with his guardian and the judge of probate to kill him, "box him up," and
ship him to a medical college for dissection. It was further revealed that
his removal was to be effected by poison. (This by the way explains a
sudden and unaccountable disinclination which he recently exhibited
toward taking medicine.) When interrogated as to whether he had a
weapon concealed on his person he showed confusion and replied evasively.
On the day following its discovery he admitted his design, and referred to
the possible killing as an act of " self-defence." He showed no regret and
did not appreciate the enormity of the contemplated crime, but was evi-
dently mortified and humiliated at its discovery. He had observed, he
said, that of late he had been scrutinized closely, and to avoid questioning
had made every effort to seclude himself. He now concludes without in-
quiry, that his thoughts were "revealed and his plot exposed through his
tell-tale expression of countenance.

Could a more striking illustration be given of the danger of discharging
such a man from the custody of an asylum ?

At the trial of Guiteau, the following conversation with the prisoner
was given in evidence: "You said if you got the consulship you would
not have taken off the President." "That is so; but you see I have put
in the Herald article that this would have made no difference." "I notice

1883.]

Wharton, Coxalgia.

101

that, but the two statements could not harmonize, and I see you use the
word 'deter;' it would have deterred you." "That is true:"

K. by his own admission would have abandoned the thought of killing
the superintendent of the asylum had his discharge been effected prior to
April 1.

Article VII.

•Report of Eight Cases of Coxalgia in which Eleven Operations of
Subcutaneous Osteotomy have been performed in the Children's
Hospital, Philadelphia. With Remarks. By H. R. Wharton, M.D.,
Surgeon to the Children's Hospital, Demonstrator of Clinical Surgery in the
University of Pennsylvania, and Assistant Surgeon to the University Hospital.

This paper records eight cases of coxalgia followed by marked de-
formity, in which eleven subcutaneous osteotomies of the femur were per-
formed. In Case I., under the care of Prof. Ashhurst, two operations
were performed ; the neck of the bone having been first divided after the
manner of Mr. Adams, and the deformity recurring, the bone being subse-
quently divided below the lesser trochanter, as in the operation recom-
mended by Mr. Gant. The same procedure was adopted in Case III.,
which was under the care of the late Dr. H. Lenox Hodge. Case II.,
also under the care of Prof. Ashhurst, was one in which the deformity
existed in both hip-joints, and both femora were divided, a short time
being allowed to intervene between the operations.

Case I Livingstone E., aged 4 years, was admitted to the Children's

Hospital October 10, 1874, with coxalgia of the right hip-joint in the
second stage. During the course of the disease numerous abscesses had
formed and had been evacuated, but the active symptoms of the disease
finally subsided, leaving a completely useless limb on account of the re-
sulting deformity, adduction and flexion of the thigh on the pelvis, and
fixation of the coxo-femoral articulation.

On November 10, 1876, Prof. Ashhurst made a subcutaneous section of
the neck of the femur after the plan devised by Mr. Adams, of London,
and brought the affected limb into good position ; the wound was closed
with a compress, saturated with compound tincture of benzoin, held in
position by adhesive straps, and an adhesive-plaster extension apparatus
was then applied to the limb, to which a weight was attached, and lateral
support was furnished to the limb by means of a long external and short
internal sand-bag. The patient did well after the operation, and presented
no unfavourable symptoms ; but, as it was found that the deformity was
gradually recurring, on April 10, 1877, Prof. Ashhurst deemed it advis-
able to divide the femur subcutaneously below the lesser trochanter ; this
was accordingly done after the method recommended by Mr. Gant, except
that the bone was approached from the outer side instead of from behind,
as appears to be Mr. Gant's practice.

102

Wharton, Coxalgia.

[July

The knife devised by Mr. Adams was used to divide the soft parts to
the bone, and the section of the latter was made with Adams's saw.

The usual dressings were applied, and the result of the operation was
perfectly satisfactory ; the patient was discharged from the hospital August
4, 1877, walking well without the aid of crutches or high-shoe.

Case II Maggie B., aged 8 years, was admitted to the Children's

Hospital January 25, 187G, with ankylosis of both hips in bad position,
having suffered from coxalgia two years before admission.

In September, 1876, Prof. Ashhurst divided the neck of the left femur
subcutaneously, doing in this case the operation recommended by Mr.
Adams; the patient did well after the operation, and, some weeks later,
Prof. Ashhurst divided the right femur subcutaneously, after Gant's
method, modified as in the preceding case.

The results of both operations were perfectly successful, and the patient
was discharged from the hospital March 9, 1877, walking well with the
aid of a high-shoe on the right foot.

Case III. — Frank G., aged 7 years, was admitted to the Children's
Hospital September 15, 1874, with coxalgia of left hip-joint in the second
stage. The deformity following the disease being marked and rendering
the limb useless, on November 10, 1870, Dr. Hodge divided the neck
of the left femur subcutaneously (Adams's operation). The patient did
well after the operation, but when he was allowed to get out of bed it was
found that the deformity had in a measure recurred.

On July 12, 1877, Dr. Hodge made a subcutaneous section of the left
femur below the lesser trochanter (Gant's operation). The patient did
well after this operation, and was discharged from the hospital September
25, 1877, walking well.

Case IV Maggie S. was admitted to the Children's Hospital with

marked deformity of left coxo-femoral articulation following coxalgia.

On May 15, 1879, Dr. Hodge made a subcutaneous section of the left
femur below the lesser trochanter; the limb was brought into good posi-
tion, and the patient did well after the operation, and was discharged from
the hospital August 18, 1879, walking well.

Case V Benjamin C, aged eight years, was admitted to the Chil-
dren's Hospital April 1, 1879, with marked deformity of the left coxo-
femoral articulation following coxalgia of some years' standing.

On May 30th, Prof. Ashhurst divided subcutaneously the left femur
below the lesser trochanter.

The patient did well after the operation, and was discharged from the
hospital September 15, 1879, walking well.

Case VI Mary P., aged 13 years, was admitted to the Children's

Hospital with marked deformity of left coxo-femoral articulation, follow-
ing coxalgia of some years' standing.

On November 26th, Dr. Ashhurst made a subcutaneous section of the
left femur below the lesser trochanter.

The patient did well after the operation, and was discharged from the
hospital February, 1880, walking well.

Case VII — Sarah B., aged 7 years, was admitted to the Children's
Hospital June 12, 1880, with coxalgia of the left coxo-femoral articula-
tion ; the active symptoms of the disease passed away, leaving the left
femur much adducted and flexed upon the pelvis.

On December 12, 1881, Dr. Wharton divided the left femur subcuta-
neously below the lesser trochanter. The limb was brought into good

1883.]

Wharton, Coxalgia.

103

position, the usual dressings were applied, and the patient did well after
the operation.

This patient was discharged from the hospital three months after the
operation, with the limb in good position and walking well.

Case VIII. — James McC, aged 9 years, was admitted to the Chil-
dren's Hospital July 31, 1882, with coxalgia of the right coxo-femoral
articulation in the third stage, with marked adduction and flexion of the
thigh on the pelvis. Efforts were made to correct the deformity by ex-
tension, which proved unavailing.

On November 25, 1882, all active symptoms of the disease having sub-
sided, and the deformity being so marked as to render the limb useless,
Dr. Wharton made a subcutaneous section of the right femur below the
lesser trochanter, which allowed the limb to be brought down into ^ood
position ; the usual dressings were applied, the patient did well after the
operation, and, in March, 1883, was walking about the ward with the aid
of a high shoe.

The results obtained by the subcutaneous section of the femur in the
above cases were most satisfactory, not only as regards the immunity
from danger in the operation, but also as regards the correction of the
deformities and restoration to use, of comparatively useless limbs.

The amount of constitutional disturbance following the operations was
insignificant, as little, or even less, than that which follows a simple frac-
ture of the femur; in no case was there excessive hemorrhage at the time
of operation, nor did there follow in any case marked febrile reaction or
suppuration ; the wounds healed as ordinary tenotomy wounds, and by
the end of the first week were generally found entirely closed, so that
further dressings could be dispensed with.

In several of the cases there was some oozing of blood-stained serum
from the wound for two or three days, but it was not profuse enough to
necessitate the removal of the dressings.

The facility with which the wounds healed in these cases can only be
explained by their subcutaneous character, for although by the operation
a compound fracture of the femur is produced, it must be remembered that
the original puncture, which is made down to the bone by Mr. Adams's
knife, is small, and that when the saw is introduced and cuts the bone,
the wound is entirely filled by its shank, by blood and by dust from the
sawn bone, so preventing the admission of air to the deeper parts of the
wound.

The mortality following the operation is very low ; Mr. Adams1 reports
twenty-four cases in which this operation was performed, with one death
from pyaemia ; in one other case death was hastened by the operation, or
rather by the prolonged suppuration which followed ; the patient died
eight months afterwards from albuminuria and phthisis. In but "one case
have I seen marked constitutional disturbance occur after this operation,

1 Transactions of International Medical Congress, Pbilada. 1876, p. 627,

104

Wharton, Coxalgia.

[July

and that was in the case of a young man of strumous constitution, a
patient in one of our large hospitals, in whom the neck of the femur was
divided subcutaneously for angular deformity following coxalgia. The
operation in this case was followed by the formation of a diffuse abscess
of the thigh, which required numerous counter-openings, and placed the
patient's life for a time in imminent danger ; this case finally terminated
in recovery with the limb in good position.

The results of reported cases bear strong testimony to the general safety
of the operation, and there is no doubt that the selection of proper cases,
and care as to the position at which the section of the bone is made, will
render this operation one of the safest in surgery.

In regard to the selection of cases, Mr. Adams considers as most favour-
able for division of the neck of the bone: (1) Cases of rheumatic anky-
losis, because in rheumatism no destruction of the bone ever exists, and
the head and neck of the bone always remain of their full natural size.
(2) Cases of ankylosis after pyasmic inflammation, most especially in its
subacute form, from which the patient often recovers ; in these cases
destruction of the bone rarely if ever exists, the cartilages only being
more or less destroyed. (3) Cases of ankylosis after traumatic inflam-
mation of the joints, in which little or no destruction of the bone occurs.
(4) The most unfavourable cases for Mr. Adams's operation are those
which occur in strumous subjects, where destruction of the head and neck
of the femur has taken place. This latter class of cases is one in which
the indication for the operation most frequently exists ; the deformity fol-
lowing coxalgia, unless corrected, often leaves the patient to go through
life a hopeless cripple, and I cannot but think that the satisfactory results
obtained in cases of this nature, by division of the bone by Gant's modifi-
cation of Mr. Adams's method, will lead to the more general adoption of
an operation which is attended with little risk, and which offers so much
for the relief of this distressing condition.

The operation may be performed with the narrow knife and saw devised
by Mr. Adams, which I think have proved most satisfactory instruments,
or a chisel and mallet may be used, as recommended by Mr. Maunder, of
London ; Macewen's osteotomes have also been used with success.

The latter instruments were used in a most interesting case of angular
ankylosis of both hips following coxalgia, in which a simultaneous
osteotomy was successfully performed by Dr. Joseph C. Hutchison, of
Brooklyn.1

The use of Adams's saw seems to me to possess the advantage of ren-
dering the operation more nearly subcutaneous, and the instrument to be
more directly under the control of the operator than the chisel struck by
the mallet, and, therefore, less likely to be followed by injury of important
surrounding structures.

3 American Journal of the Medical Sciences, April, 1883.

1883.]

Wharton, Coxalgia.

105

The only cases where the substitution of the chisel for the saw appears
to present advantages are those where a great thickness' of bone, as in
the head of the tibia, or the condyles of the femur are to be divided ; here
the great width of the bones, their subcutaneous position, and the small
extent of cutting surface of the saw, seem to render the use of the chisel
advisable.

As regards the point at which the section of the bone should be made
some difference of opinion exists ; Mr. Adams, to whom the introduction
•of this operation is due, recommended that the section should be made
through the neck of the femur, entering the knife a little above the top
of the great trochanter, and introducing the saw through the same wound ;
and there is little doubt that this operation possesses many advantages in
properly selected cases.

But from the fact that subcutaneous osteotomy is frequently required to
correct the deformity after coxalgia, where great destruction of the head
and neck of the femur has taken place, the modification of the operation
suggested by Mr. Gant, is often to be preferred. It consists in dividing
the shaft of the femur subcutaneously just below the position of the smaller
trochanter, and for its performance instruments similar to those used by
Mr. Adams are required.

Section of the femur at this point, below the lesser trochanter, secures
a division of the bone at a point where its structure is comparatively
healthy, whereas its division through the diseased tissues of its neck, it
this still exists, is capable of renewing active inflammation in tissues
which are most susceptible to the inflammatory accidents following trau-
matisms. Section of the femur below the lesser trochanter, in addition
to the other advantages previously mentioned, has in our hands, at the
Children's Hospital, given better results in correcting the deformity, and
in lessening the chances of its recurrence ; this can be seen by reference
to Cases Land III., where both operations were performed, and the latter
in each case gave a most satisfactory result, while the former — division of
the neck of the bone— had been followed by reproduction of the deformity.

This may be explained by the fact that the deformity in these cases is
caused by contraction of the psoas magnus and iliacus internus muscles.
These muscles being inserted into the lesser trochanter and the shaft of
the femur below it, remain, after section of the neck of the femur, attached
to the lower portion of the bone, and hold the thigh in a flexed position
as before.

When the section is made below the lesser trochanter, the psoas and
iliacus muscles remain attached to the upper fragment, and do not, there-
fore, interfere with the straightening of the thigh as they can no longer
influence the shaft of the bone.

There is also an advantage in making the section as near the lower
trochanter as possible, for, if the upper fragment be short, the angle made

106

Mackenzie, Nasal Cough.

[July

at the point of union is less perceptible and the limb has a more natural
appearance. In making the section below the lesser trochanter, we have
found it best to insert the knife and saw on the outer and posterior portion
of the thigh, and to divide the bone from before backwards; with care
there can be no risk of injuring either the femoral vessels and anterior
crural nerve on the inner side, or the great sciatic nerve behind.

Article VIII.

Ox Nasal Cough, and the Existence of a Sensitive Reflex Akea in
the Nose.1 By John N. Mackenzie, M.D., of Baltimore, Md., Surgeon
to the Baltimore Eye, Ear, and Throat Charity Hospital.

The object of this communication is to direct attention to the great
frequency o f cough as a symptom of nasal disease, and to indicate, as far
as possible, the manner of its production.

The dependence of cough upon irritation of the external auditory meatus
and pharyngo-tracheal membrane is well known, and the terms " ear"
and " laryngeal" cough have passed into current use among medical men.
It is also quite possible that the reflex act may originate primarily in
morbid conditions of various other organs of the body, and the familiar
expressions " stomach" and " liver" cough would seem to indicate that
such a causal connection had been accepted as true of some of the ab-
dominal viscera. This interdependence has, however, never been demon-
strated by experiment, nor are the clinical data sufficient to warrant the
unqualified acceptance of this alleged correlation.

My attention was first directed to the study of nose cough by the
repeated observation, that, during the manipulation of instruments (probe,
forceps, snare, Eustachian catheter, etc.) within the nasal fossae, paroxysms
of coughing were induced which only subsided upon the withdrawal of
the instrument, or upon changing its position in the nasal chamber. The
cough varied greatly in character, from a succession of short expiratory
acts to convulsive paroxysms which interfered greatly with instrumenta-
tion. These attacks occurred, furthermore, only when the foreign body
came in contact with the deeper portions of the nostril ; in several cases
where the snare was used they seemed to be excited only at one particular
spot in its passage through the nose, and ceased when the loop entered
the naso-pharynx. My clinical experience, too, furnished me with cases
where distressing cough existed, whose etiology was rendered obscure by
the absence of disease or irritation in pharynx, windpipe, or lungs. In

1 Presented as a candidate's thesis to the Maryland Academy of Medicine, May 12,
1883.

1883.]

Mackenzie, Nasal Cough.

107

this latter ease, one of two conditions was invariably present, viz., either
a hypersemic or slightly swollen state of the mucous membrane chiefly
affecting the turbinated bodies, or pronounced hypertrophic enlargement
of these structures.

It was in the clinical study of this reflex cough that I was led to assume
the existence of a certain area or areas in the nose, the irritation of which
would culminate in a reflex act or in a series of reflected phenomena.
The existence of such an area had been demonstrated in the larynx and
trachea, and it seemed, therefore, legitimate to assume the presence of
similar spots in the nasal chamber. The well-known occurrence of reflex
asthmatic attacks in some cases of nasal polypus and their absence in
others, together with similar observations which I had made in regard to
hypertrophic nasal catarrh, lent further support to the hypothesis of a reflex
area.

In order, if possible, to throw some light upon this subject, I made a
series of experiments upon a large number of hospital patients, upon my-
self, and upon several of my medical friends, who were kind enough to
place their nasal organs at the disposal of science. The experiments con-
sisted essentially in the systematic irritation of all accessible portions of
the nasal mucous membrane, the irritants used being silver and rubber
probes, and the steel wire, such as used in the polyp-snare.

It may be here remarked, that the nose of the negro is admirably
adapted for experiment on account of the great capacity of the nasal
chambers anteriorly, rendering dilatation by artificial means unnecessary,
and hence eliminating a source of error which might vitiate the result ot
the experiment. The great width of the vestibule, too, brings the ante-
rior ends of the turbinated bones into greater prominence, or rather, their
mucous covering, which, in the black race, is much more puffy anteriorly
than in the white man, giving the appearance of what in the latter
would be taken for an anterior hypertrophy. It is also very flabby, col-
lapses under the probe, and can be pressed with ease against the external
wall of the nostril.

The patients experimented on presented varying degrees of suscepti-
bility to irritation ; in some instances, the slightest touch was sufficient to
provoke the reflex act, whilst in others it was only excited by repeated
irritation or long-continued pressure. In some cases no reflex whatever
could be obtained. The results of these experiments may be briefly given
as follows : —

So long as the stimulation was confined to the vestibule — to the interior
of the fleshy, cartilaginous nose — the result was negative ; no reflex action
was obtained. The sensation created was simply that of a foreign body,
or, if the stimulus was increased, a feeling of pain. So far, I have been
unable to excite cough by stimulation of this part of the nose. Irritation
of the membrane clothing the anterior extremities of the middle and infe-

108

Mackenzie, Nasal Cough.

[July

rior turbinated bones was in some instances negative ; in others a half-
tendency to cough was produced which increased as the irritant was
applied farther back, and finally culminated in the act when it was
directed upon the posterior half of the turbinated body. Irritation of
the floor of the nose was negative in result. In cases where stimulation
of the remaining portions of the nose failed to excite them, paroxysms
of cough were induced when the irritant was applied to the mucous mem-
brane covering both the inferior and middle turbinated bones ; but the
act was most constantly obtained from the posterior end of the inferior
turbinated bone and the portion of the septum immediately opposite.
Indeed, my experiments seem, thus far, to show that these portions are
the most sensitive spots in the reflex area. In passing along the pars
nasalis of the roof, coughing was occasionally produced when the probe
or wire impinged on the anterior extremity of the middle turbinated
bone ; but no decided results could be obtained from the upper olfactory
region.

We have thus experimental proof that all parts of the nasal mucous
membrane are not equally susceptible to the impression by which reflex
cough is produced, and, furthermore, that the cough or reflex area is
probably limited to the mucous membrane covering the middle and infe-
rior turbinated bodies and the posterior half of the septum. Now this is
the area occupied by the erectile tissue of the nose, and it is hard to resist
the conclusion, that this structure is in some way connected with the
evolution of the reflex act, and that the peculiar susceptibility to irrita-
tion is to a great extent intimately associated with its physiological func-
tions, whatever they may be.

Roughly speaking, the greater the congestion or inflammation, the more
constant the reflex obtained. I have succeeded, however, in producing
violent paroxysms of laryngeal cough by simply touching, with the aid
of the rhinoscope, the posterior extremity of the inferior turbinated bone
in a person whose nose was free from disease. In some cases, stoppage
of the nostril and discharge of mucus was produced, whilst in others this
was not observed.

That the sensitive area is principally confined to the parts already
indicated, viz., the posterior half of the inferior turbinated body and
septum, is furthermore rendered exceedingly probable by the following
clinical facts : —

(1) That in cases where reflex cough exists, these are the portions chiefly,

if not solely, involved.

(2) That the act may be produced here at will by artificial stimulation of

the parts invaded by the morbid process.

(3) That it may be dissipated by local applications to, or removal of,

the membrane covering the diseased surface.

1883.]

Mackenzie, Nasal Cough,

109

(4) That foreign bodies, such as pins, lodging in this area sometimes

give rise to cough, which latter is not observed when they become
impacted in other portions of the nose.

(5) That polypi give rise to reflex phenomena only when they arise from,

or impinge upon, the sensitive portions of the area.

(6) That where complete atrophy of the turbinated structures exists, as,

for example, in ozsena, reflex cough is not present, nor can it be
induced by artificial stimulation.

These facts are the outcome of personal experience, and, as they repre-
sent the resultof solitary observation, are, of course, open to correction.
I have never seen, nor do 1 know of a single case where a foreign sub-
stance impacted in the non-sensitive portions of the nose has given rise to
cough ; but I do know of cases where that act was excited by their pres-
ence in the reflex area. In regard to reflex asthma from polypi, the litera-
ture accessible to me shows, that, where the position of the tumour is
accurately defined by the reporter, it is always in the posterior portions of
the nostril, in a situation which would lead to irritation of the sensitive
tract.

The following cases may be adduced as illustrative of the above re-
marks : —

Case I. Miss S., a robust, healthy young woman of fine physique, but
of somewhat nervous temperament, came in December, 1881, at the solici-
tation of her friends, to consult me on account of a dry, hacking cough,
dyspnoea on slight exertion, and occasional night sweats. The association
of this suspicious triad of symptoms, with .feverish exacerbations in the
afternoon, loss of appetite, irregular, scanty menstruation, the occasional
presence of small quantities of blood in the expectoration, and progressive
deafness, had led her family to anticipate medical opinion in the matter,
and to refer her ailments to consumption.

Beyond a few small mucous rales, nothing abnormal wras discovered in
the lungs, and the heart performed its work in a perfectly natural manner.
The laryngeal membrane showed no signs of inflammation, but during the
examination became congested. Both tympanic membranes were sunken,
but movable ; the malleus handle prominent and congested. Ordinary
conversation was heard with difficulty ; improved by inflation of the drum
cavity. The orifices of the Eustachian tubes were swollen and filled
with mucus.

The starting-point of all her trouble was finally discovered in the nose,
which was almost completely occluded by hypertrophic thickening of the
mucous membrane over the middle and lower turbinated bones of both
sides. The osseous structure was also developed to an abnormal extent,
and assisted in the occlusion of the nostrils. I explained the situation to
the patient, and assured her that an operation would certainly relieve, and
perhaps completely dissipate, the disorders from which she suffered. This
she consented to, and the inferior hypertrophied masses were removed —
seven days intervening between the two operations. Vapour of creasote,
carbolized and astringent sprays, inflation of the middle ear with the vapour
of the benzoate of iodine constituted the remainder of the treatment. Im-

110

Mackenzie, Nasal Cough.

[July

provement at once began, and in seven days after the second operation all
symptoms referable to the chest had disappeared, and the discharge from
the nose had ceased to trouble her. Two weeks later she could hear ordi-
nary conversation with ease, and by the middle of the following February
the whispered voice was heard distinctly in each ear at the distance of
twenty feet.

Case II. A negro man came to my clinic at the hospital to be treated for
a severe paroxysmal cough which occurred at irregular intervals, and which,
together with the occasional expectoration of small quantities of mucus
tinged with blood, had led him to infer the existence of some pulmonary
affection. The attacks came on both in the night and during the day-
time, and seemed, according to his story, to vary in severity with the
amount of a discharge from a nasal catarrh from which he had suffered
for a number of months. His general health was excellent, and beyond
a very slightly hyperjemic condition of the ventricular bands and vocal
cords, nothing could be detected in the lower respiratory organs to war-
rant the diagnosis of disease. The pathological appearances in the nose
and upper pharynx were those of ordinary hypertrophic catarrh, affecting
chiefly the inferior and middle turbinated structures and the septum, the
mucous membrane over the inferior turbinated body being moderately
swollen and intensely hypercemic. A bent probe was introduced, with the
aid of the mirror, behind the velum, and made to impinge on the posterior
end of the lower turbinated bone. Immediately a violent paroxysm of
coughing was induced, which he assured me was identical with those from
which he suffered. At no other portion of the nasal membrane could the
attacks be provoked. The experiment was performed repeatedly, and
always with the same result. Looking upon the paroxysm as a purely
reflex phenomenon, the treatment was confined to the local application of
astringent solutions to the congested, swollen area. The patient was
directed to use a salt and soda spray at home, followed by the insufflation
of finely powdered boracic acid. No other treatment was used. After
the third application the coughing-spells became less severe, and the in-
terval between them more prolonged ; at the end of two weeks they had
completely disappeared, together with the hyperemia and swelling of the
mucous membrane over the inferior turbinated bones. The nasal dis-
charge had diminished to such an extent that the patient, finding no
further inconvenience from his catarrh, ceased attendance at the clinic.

Case III. A young girl, of healthy appearance and good physique,
consulted me on account of a short, dry, hacking cough, with which she
had been troubled for several weeks. The cough was most severe when
she laid down to rest at night. She also complained of slight sore-throat
and difficulty in swallowing. She insisted that her nose had never given
her the slightest inconvenience, and that, strange to say, she very rarely
suffered from coryza. The lower respiratory passages presented no signs
of disease ; but the left tonsil was the seat of chronic follicular inflamma-
tion ; the follicles were swollen and filled with cheesy deposits; the gland
itself was slightly enlarged. I removed the diseased tonsil, and dismissed
her, deferring the examination of the nose until her next visit, as she had
denied disease of that organ, and as I was anxious to get through my
work that day as quickly as possible. Moreover, I thought that the dis-
eased tonsil might possibly be the originator of the reflex cough, and that
its ablation would effect a cure.

Several days afterwards she returned to say that her sore-throat had

1883.]

Mackenzie, Nasal Cough.

Ill

disappeared, and that she could swallow with perfect ease ; but that her
cough still remained, in fact seemed to have increased somewhat in
severity. A thorough examination of the nose was now made. Nothing
abnormal was detected in either side, exeept a hypersemic and very puffy
condition of the membrane covering the inferior turbinated bone of the
left nostril. Upon touching this lightly with a silver probe, the short,
explosive cough of which she complained was at once produced. The act
was completely beyond her control, and could be excited only by irritation
of the turbinated structure. As the swelling was obviously due to a more
or less acute engorgement of the turbinated tissues, and not to chronic in-
flammation of the same, the treatment consisted in the topical application
to the diseased surface alone of sedative and astringent remedies. Four
or five pencillings caused the cough and swelling to disappear ; to return,
however, when the local applications were discontinued. Upon their re-
sumption, the cough began to grow less severe, and finally ceased alto-
gether. As she has not returned for further treatment, it may be assumed
that the cure has been permanent.

Case IV. A gentleman whom I had treated six months previously for
catarrhal laryngitis, consulted me on account of a disagreeable, hacking
cough, and pain in the throat, which he referred to the region of the crico-
thyroid space. The sensation complained of was that of a foreign body in
the larynx, and was not constant, disappearing sometimes for hours at a time.
There was no expectoration with the cough ; but he remarked incidentally,
that for some time past he had noticed an accumulation of mucus in the
nose and back of the throat, and that his voice became easily fatigued in
singing. It was especially after such exercise of the voice that the tick-
ling in the larynx and paroxysms of cough were produced. Before com-
ing to my office he had used a stimulating inhalation which I had pre-
scribed for him the winter before, and from which he had then derived con-
siderable benefit. On this occasion, however, it had failed to exert any in-
fluence upon the cough. As I could discover nothing in the larynx or lungs
to account for the symptoms which he described, and as inspection and
probing of the anterior portions of the nose revealed nothing abnormal, I
had begun to suspect that the phenomena might be ascribed to a somewhat
exalted imagination, when the rhinoscope revealed the origin of his trou-
ble in a swollen, intensely hypersemic condition of the inferior turbinated
bodies. These latter were covered with a film of mucus, which extended
also over the pharyngeal vault. This was carefully removed, and the red-
dened turbinated body lightly touched with a bent probe. Pain was at
once felt in the larynx, which caused him to grasp the throat with his
hand. This was immediately succeeded by a paroxysm of coughing which
lasted for nearly a minute. The sensation of pain and cough produced by
touching the inflamed turbinated structures was compared by him to an
aggravation of his existing complaint, the pain being slightly more pro-
nounced in the former case, and radiating into the lower part of the trachea.
Local treatment of the diseased nasal mucous membrane was at once in-
stituted with marked relief to the symptoms.

Case V. A well-known physician of this city had suffered for over
twenty years from -chronic sore-throat, for which he had undergone every
variety of treatment. His case, apart from a feature to be presently
mentioned, presented nothing out of the ordinary run of similar cases of
old catarrhal disease of the upper respiratory tract. He referred all his
trouble to the larynx and pharynx, and when questioned as to the existence

112

Mackenzie, Nasal Cough.

[July

of nasal disease, seemed convinced that such a condition played no part
whatsoever in the production of his laryngeal catarrh. Upon retiring at
night and turning upon his left side, as was his wont, he was seized with
involuntary and uncontrollable paroxysms of coughing, which only sub-
sided when he laid upon the opposite side. He also complained of a sen-
sation, as of a heavy weight in the back of the throat, which became more
pronounced toward morning. This state of affairs had lasted for a number
of years, and had become a source of great annoyance to him, as he could
not explain the curious relationship between cough and position, nor could
those of his medical friends whom he consulted on the subject, enlighten
him as to the etiology of the paroxysms. His throat had been treated
after the most orthodox manner, and his epiglottis had been cauterized
under the impression that its inflamed condition was the starting point of
the cough. These means, had, however, proved of no avail, and he had
finally accepted the cough, with philosophic resolution, as the inseparable
associate of his life. Recently, however, the paroxysms had become more
severe and annoying, and one day he called on me for a professional opinion.

The mucous membrane of the entire naso-laryngeal tract presented the
ordinary typical appearances of chronic catarrhal inflammation of these
organs. The pharynx was granular and irritable. The posterior ex-
tremity of the right inferior turbinated bone was the seat of a small
grayish-white hypertrophy which had not, however, encroached to any
great extent upon the lumen of the corresponding inferior meatus. The
middle and superior turbinated bodies of the same side were moderately
swollen and very hyperamiic. There was also a moderate amount of hyper-
trophic enlargement on either side of the posterior half of the septum. A
similar condition existed on the middle and superior turbinated bodies of
the opposite side. There was no anterior hypertrophy of any of the turbi-
nated structures ; but the posterior part of the left inferior meatus was
completely blocked by a large, irregularly oval, vascular hypertrophy of
the posterior extremity of the inferior turbinated body of that side. This,
I assured him, Avas the fons et origo of all his trouble, and the inflamma-
tion of the pharyngo-laryngeal tract was secondary to a chronic hyper-
trophic nasal catarrh ; that the cough was reflex in character, and depended
upon the hypertrophic enlargement of the posterior end of the left inferior
turbinated body, an area which was especially concerned in the evolution of
reflex phenomena. I furthermore gave it as my opinion, that the removal
of the hypertrophied mass would, in all probability, dissipate the cough,
and proposed an operation then and there. This he refused, and I treated
him under protest for several days with an astringent and alterative spray.
As no effect was produced upon the cough by this treatment, he consented
at last to the operation. The hypertrophy of the left turbinated body — a
growth about the size of a small strawberry — was accordingly removed
with ease by means of the snare, the wound allowed to bleed for some
time to encourage evacuation of the erectile cells, and the nostril finally
plugged with carbolized absorbent cotton.

The effect was almost magical. The next day he came to tell me that
he had not coughed one-sixteenth as much as before the operation, and
that if he remained in his then condition, he would be perfectly satisfied
with the result. A few days later, when cicatrization was complete, the
cough had almost entirely disappeared, in fact, was hardly noticeable, and
he could lie upon the left side with perfect comfort and freedom from
cough, a pleasure he had not experienced for many years.

1883.]

Mackenzie, Nasal Cough.

113

Case VI. A middle-aged gentleman placed himself under my care to
be treated, as he supposed, for chronic bronchitis. He had for a number
of years been subject to attacks of influenza, the disease always starting
as an acute coryza and ending in a bronchial catarrh. He volunteered
the information, that the cough was always most severe and harassing
when the inflammatory process was confined to the nose, and abated con-
siderably when it descended to the lower portions of the respiratory tract.
The intervals between the attacks had gradually become less and less, so
that the cough was almost constantly present. It was short, "hacking, and
unaccompanied by expectoration. In bodily operations requiring unusual
exertion, he was compelled to breathe exclusively through the mouth, and
became very readily fatigued. Even in walking a great distance, or in
going up stairs, the dyspnoea was sufficient to give him considerable
anxiety. He had consulted a specialist, who informed him that all his
trouble arose from inflammation of the windpipe and bronchial tubes, and
who treated him for a number of months with laryngeal sprays, stimulant
inhalations, etc. No effect was produced upon the cough, which continued,
in spite of treatment, with all its original severity.

On careful auscultation, a few mucous rales were discovered here and
there in the chest, in not sufficient number, however, to warrant the diag-
nosis of chronic bronchitis. The larynx was congested. The mucous
membrane lining the posterior nares was intensely hypersemic ; the infe-
rior turbinated bone of each side swollen and hypertrophied. Well-marked
hypertrophic enlargement of the cavernous tissue of the septum was also
present, . especially on the right side, which, together with the inferior
hypertrophy, produced almost complete occlusion of the inferior meatus
of the corresponding nostril. Anteriorly, the nasal fossae presented nothing
worthy of special remark. Under the assumption that the inflammatory
engorgement of the turbinated structures was the most important, if not
the sole factor in the production of the cough, the treatment was directed
to the local nasal affection. He was given a carbolized alkaline spray for
use at home, and a tar vapour to inhale through the nostrils. The nasal
cavities being thoroughly cleansed, local applications of ammonio-ferric
alum and zinc were made to the diseased turbinated bodies. At first the
applications themselves gave rise to cough ; but this tendency grew less as
the congestion of the membrane began to disappear. With its subsidence
the patient commenced to improve, and the cough ceased to give him in-
convenience. As long as the local treatment was continued, there was a
marked diminution in the number and severity of the cough paroxysms.
Upon its discontinuance, both the cough and congestion reappeared. As
he has never been willing to submit to an operation, I am still holding his
cough in abeyance by local applications.

Case VII. The winter before last a gentleman came to my office to
have his chest examined. His history was briefly as follows : For nearly
two years he had suffered almost uninterruptedly from a distressing, hacking
cough, which was most severe in the early morning and when he laid down
to rest at night. He was extremely subject to cold in the head, and during
inclement weather his voice would become hoarse and remain so for days
at a time. For six months prior to seeking advice he had been growing
gradually deaf, and had begun to suffer from tinnitus aurium. At first he
paid no attention to the cough ; but it had finally become so harassing
that he had temporarily given up his business and gone abroad. Very
little benefit was derived from his European trip, and he returned home in
No. CLXXI July 1883. 8

114

Mackenzie, Nasal Cough.

[July

much the same condition in which he had left. Travel in the West was
next tried, but without any effect upon the cough, which had increased
rather than diminished in severity.

A careful examination of the internal organs disclosed nothing abnor-
mal. The pharynx was congested, and its- follicles somewhat swollen ;
but otherwise its mucous membrane presented nothing worthy of remark.
During the laryngoscopy examination the partially injected laryngeal
membrane became covered with a crimson blush, which faded slowly when
the mirror was withdrawn. On rhinoscopic examination, the posterior
ends of the inferior turbinated bodies were found greatly hypertrophied,
especially that of the left side, which lay across the floor of the nostril,
and almost completely precluded the passage of air through the meatus.
The mucous membrane of the middle turbinated bodies and septum was
reddened and turgid, the engorged condition being more pronounced in
the posterior portions of the nose. The mouths of the Eustachian tubes
were swollen, reddened, and filled with slimy mucus. Both drum cavities
were the seat of catarrhal inflammation.

The sequence of events here was sufficiently obvious. As the patient,
however, was loath to undergo an operation, it was determined to defer
instrumental interference until less radical measures had been fairly tried.
He was accordingly treated with sprays, inhalations, inflation, -tonics,
etc. In the course of a month marked improvement had taken place ; the
cough was much less severe, and the hearing notably improved. Upon
the slightest change in the weather, however, the symptoms would recur.
Especially noticeable was the sudden laryngeal congestion which would
occur during the aggravation of the nasal inflammation, and which would
immediately disappear when the latter was brought under subjection.
This alternate subsidence and reappearance of the cough continued until
the early part of last February, when he adopted my view of his case, and
consented to the removal of the h}rpertrophied structures. In a few days
after their ablation the cough had entirely disappeared. Shortly after-
wards he went South on a pleasure trip, taking with him an array of
medicines for use in case of a return of his original trouble. Fortunately
he has had no occasion to resort to them ; and he tells me that since the
operation he has had no return of the cough, and that apart from the
occasional accumulation of mucus in the pharynx, requiring hawking
efforts for its removal, he is perfectly comfortable, and considers himself
thoroughly cured.

These cases can be multiplied. Indeed, nasal cough has become so
common in my experience, that I have long since ceased to regard it as
a curiosity. It is worthy of remark, that in a fair proportion of cases
there are few, if any, sj^mptoms which would direct the attention to dis-
ease of the nose, and this fact emphasizes the importance of examining
the nasal chambers in all cases of the kind, even though the testimony
of the patient may lead to neglect of their systematic exploration.

My clinical observation leads me to the belief that reflected irritation
from nasal disease plays a not inconspicuous part in the etiology of laryn-
geal congestion and inflammation. The short, hacking cough and hyper-
emia of the larynx which occur in acute coryza are probably more often
explicable on the theory of reflex action than upon the extension of the

1883.]

Mackenzie, Nasal Cough.

115

inflammation to the laryngeal vestibule. The physiological, explanation
of this phenomenon may possibly be found in the doctrine of correlated
areas,1 the reflex taking place through the vaso-dilator nerves from the
superior cervical ganglion of the sympathetic. In chronic coryza, on the
other hand, the constant laryngeal hyperemia induced by reflex nasal
irritation, augmented, perhaps, by the frequent occurrence of cough parox-
ysms, may, if prolonged, eventuate in catarrhal conditions of that organ.
In other words, on theoretical grounds, and clinical observation would
seem to sustain them, it is legitimate to assume the existence of a reflex
laryngitis evoked through the constant irritation of the vaso-motor centres
from chronic nasal inflammation.

Clinical and experimental investigation would appear, then, to lead to
the following conclusions : —

(1) That in the nose there exists a definite, well-defined sensitive area,

whose stimulation, either through a local pathological process, or
through the action of an irritant introduced from without, is capable
of producing an excitation, which finds its expression in a reflex
act, or in a series of reflected phenomena.

(2) That this sensitive area corresponds, in all probability, with that

portion of the nasal mucous membrane which covers the turbi-
nated corpora cavernosa.

(3) That reflex cough is produced only by stimulation of this area, and

is only exceptionally evoked when the irritant is applied to other
portions of the nasal mucous membrane.

(4) That all parts of this area are not equally capable of generating the

reflex act, the most sensitive spot being probably represented by
that portion of the membrane which clothes the posterior extremi-
ties of the inferior turbinated body and that of the septum imme-
diately opposite.

(5) That the tendency to reflex action varies in different individuals, and

is probably dependent upon the varying degree of excitability of
the erectile tissue. In some, the slightest touch is sufficient to ex-
cite it, in others, chronic hyperemia or hypertrophy of the cavern-
ous bodies seems to evoke it by constant irritation of the reflex
centres, as occurs in similar conditions of other erectile organs, as,
for example, the clitoris.

(6) That this exaggerated or disordered functional activity of the area

may possibly throw some light on the physiological destiny of the
erectile bodies. Among other properties which they possess, may
they not act as- sentinels to guard the lower air-passages and pha-
rynx against the entrance of foreign bodies, noxious exhalations, and
other injurious agents to which they might otherwise be exposed?

1 Comp. Woakes, Deafness, Giddiness, and Noises in the Head, Lond., 1880, p. 74
et seq., on the Mechanism of Ear-cough.

116

Duhring, Paget's Disease of the Nipple.

[July

Apart from their physiological interest, the practical importance of the
above facts in a diagnostic and therapeutic point of view is sufficiently
obvious, Therein lies the explanation of many obscure cases of cough
which heretofore have received no satisfactory solution, and their recog-
nition is the key to their successful treatment.

Note. — The following are the only references to the subject of nose-cough
that I can find in the literature accessible to me. Dr. Hack, in the Berliner
Minis die Wochenschrjft, No. 25, 1882, S. 381, relates a case where paroxysms
of spasmodic cough, induced by a fibrous polyp which sprang from the right
middle turbinated bone, were dissipated by removal of the growth. He regards
the case as unique, but adds, that in the course of some physiological experiments
on the normal nasal membrane, he had, in a small proportion of cases, noticed
convulsive motions of the laryngeal adductors, which sometimes amounted to
complete closure of the glottis, followed by an explosive cough-like sound, and
suggests that this may also happen under pathological conditions of the nasal
membrane.

In the Archives of Laryngology, vol. iii. No. 3, p. 240, 1882, Dr. Seiler re-
ports two cases. In one, severe spasmodic cough, accompanied by a peculiar
grunting or barking noise, was dependent upon a deflected septum and a large
anterior turbinated hypertrophy ; in the other, an excoriation of the mucous
membrane of the septum gave rise to reflex cough, which was relieved by treat-
ment of the nasal affection. Dr. S. observes, that he has not found a single
instance in which the irritation causing reflax cough was seated in the nasal mem-
brane. He seems, furthermore, to regard the direct irritation of the inter-ary-
tenoid fold (laryngeal cough centre) by mucus dropping from the post-nasal space,
as an important factor in the production of the cough in the two cases described.
It is quite certain that cough may be, and is, often produced in the manner sug-
gested ; but in that case it obviously cannot be regarded as nasal, i. e., due to an
irritation originating in the mucous membrane of the nose.

Article IX.

Two Cases of "Paget's Disease of the Nipple." By Louis A.
Duhring, M.D., Prof, of Skin Diseases in the University of Pennsylvania.

Two well-marked typical examples of this rare disease have within the
year come under my observation. The notes are of interest, as showing
the natural course of the process and the obstinacy of the lesions to treat-
ment. I shall not at the present time enter upon discussion as to the
nature of the disease, nor shall I refer to the views or the labours of other
observers on the subject, beyond the mere statement that attention was
first directed to the disease by Sir James Paget, in 1874, and that since
cases have been reported by Munro, Lawson, Napier, Butlin, Henry Mor-
ris, and others. It may also be stated, that particular study has been
bestowed upon the disease by Thin, especially with regard to its nature,
who has proposed to term it " malignant papillary dermatitis." The dis-
ease has received but little notice outside of Great Britain. In this coun-
try but few cases are on record. By the majority of practitioners it is

1883.]

Duhring, Paget's Disease of the Nipple.

117

regarded as u chronic eczema of the nipple," and, indeed, most of the re-
ported cases bear this heading, accompanied, perhaps, by an interrogation
mark. That it is not an eczema, but that it is a peculiar disease with a
malignant tendency, the following cases will show.

Case I. Mrs. L — , aged 65, spare, and in average health, was sent to
me by Dr. J. D. Strawbridge, of Danville, Pa., on March 23, 1882, for
advice and treatment concerning a chronic, obstinate disease of the right
nipple, areola, and breast, of an eczematous nature. The lady, who was
intelligent, gave this account of the disease. It began ten years ago in
the centre of the nipple in the form of a " roughness" with slight scaling.
This continued for a period of six months, with at times slight oozing and
crusting, without, however, Assuring or becoming excoriated. It was treated
with "caustics" for the next six months, at the end of which time the
whole nipple was destroyed, as a result either of the disease or of treatment.
From this date to the present time, a period of nine years, it has been
gradually spreading, at first over the areola, then in the course of a few
years over the central portion of the breast, the disease being apparently
superficial, and of a chronic inflammatory nature, but little different in its
general character from eczema of this region. It has been accompanied
by a variable amount of oozing, excoriation and crusting, and with almost
constant itching, which of late has been excessive. The itching was
comparatively slight during the first five years, but for the last two or
three years it has been severe and constant. Within the last two years,
moreover, the region of the nipple has become sunken, puckered, and
ulcerated, while the whole breast has enlarged and has become fuller and
firmer. At times it has felt tender and sore. No lumps or nodules,
however, have at any time been felt. The lymphatic glands have never
been affected. The treatment had, at intervals during the ten years, been
vigorously pushed on the part of several physicians, the remedies used
having been numerous and varied, including tar, chloral, carbolic acid,
and iodoform ; internally, arsenic was repeatedly prescribed, but the sys-
tem never tolerated its use. There is no history of any similar disease,
nor of cancer, in the family.

The following notes were recorded at the first examination : The dis-
ease occupies the central portion of the breast, and consists of an irregu-
larly shaped, somewhat circular, sharply defined, chronically -inflamed
patch, about two and a half inches in diameter, somewhat excoriated,
slightly crusted, and scaly. The colour is a bright crimson red, and is
much more vivid than that usually met with in eczema. In the central
part of the lesion it is intense. It is less marked as the periphery is ap-
proached. The nipple has disappeared, its site being sunken and the seat
of an irregularly rounded ulcer a half inch in diameter and a quarter inch
in depth, with a granular, violaceous red base. The secretion is scanty.
The areola, too, has gone. The patch is smooth and firm, and is con-
siderably thickened, the border being well defined and slightly elevated.
The amount of discharge from the lesion is slight. The subjective symp-
toms consist of pain and itching. At times (more frequently during the
last year) slight darting pains through the breast are experienced. Itching
is constantly present, and is very annoying. In the opinion of the patient,
this is the most distressing symptom of the disease.

The patient was placed upon an ointment of pyrogallic acid, consisting
of a drachm and a half of the acid, five drachms of resin cerate, and two

118

Duhring, Paget's Disease of the Nipple.

[July

drachms of lard. A week afterwards an extensive blackish crust had
formed, which was removed with a poultice, and the open wound treated
with a simple ointment. Two weeks later the pyrogallic acid ointment of
increased strength, two and a half drachms to the ounce, was again used.
Under this remedy, which acted as a caustic, together with repeated poul-
ticing when a thick eschar formed, an open suppurating wound was pro-
duced. This treatment was persevered with for six weeks, when the wound
was allowed to granulate under a simple emollient ointment. It was noticed
that as long as the pyrogallic acid ointment was applied the itching was
either in abeyance or entirely absent, returning as soon as this was aban-
doned for a simple ointment. During the summer the wound, including
the ulcer, healed over, became paler, and the breast was in every way more
comfortable, but three months afterwards the disease gradually relapsed
into its former state. In October, 1882, a vigorous treatment with inunc-
tions of tar ointment, and later with sapo viridis and tar ointment was insti-
tuted, but the tar produced redness, heat, and swelling, and had to be dis-
continued. The itching was subsequently markedly relieved by a lotion
consisting of a drachm each of sulphate of zinc and sulphuret of potash, a
half drachm of glycerine, and four ounces of water. A month later, fric-
tions with sapo viridis and inunctions with sulphur ointments of different
strengths were resorted to, but without benefit.

On the 16th of December, 1882, in consultation with Dr. Strawbridge,
and with the assistance of Dr. Steiwagon, the wound was operated upon
with the dermal curette, or scraping-spoon, the patient being under ether.
Much of the tissue of the general surface of the patch was found to be soft,
as in degenerating lupus vulgaris, and came away readily, but about the
region of the nipple the tissues were tough, and could be removed only
with difficulty. A cavity three-quarters of an incli in depth and an inch
in width, was made in the site of the nipple. The wound was dressed
with simple ointment, and in two months had healed so kindly that it was
thought a cure would probably result. But such was not the case, for it
now began to reappear, accompanied with itching, and in six weeks had
resumed its former characteristics. Excision of the whole gland was now
advised, but at the time of writing the patient has not decided to submit
to the operation.

Case II. Mrs. S. A. B., aged 40, brunette, spare and debilitated, the
mother of three children, applied to me October 15, 1882, for advice con-
cerning a chronic inflammatory disease of the skin affecting the left breast
and nipple, which she stated had defied the most varied treatment. The
disease had begun six years before, in the form of a fissure on the nipple,
which persisted, accompanied with slight oozing and crusting, and with
itching, for about a year, without much change, when under the use of
ointments and poultices, the disease began to spread slowly over the
nipple. Soon the nipple showed signs of contracting and of sinking into
the breast, and during the next three years, becoming smaller each year,
entirely disappeared. After this the disease spread slowly around the nip-
ple, involving the areola, accompanied by slight oozing from time to time
of a puriform nature, with itching, which has been gaining in intensity from
year to year. At first this latter symptom was insignificant, but for the
last three years it has been constant and most violent; of late it has been
almost intolerable. At first .the increase in the size of the lesion was
scarcely perceptible from year to year, but during the last six months it
has been much more rapid.

1883.]

DuhrinGt , Paget's Disease of the Nipple.

119

Upon examination the affected breast is noted to be small, but is larger,
fuller, and firmer than the sound one. In places it is distinctly lumpy,
hard, and even knotted, feeling like an ordinary scirrhous in the early
stage. This indurated state of the gland, she states, is a recent develop-
ment, The lymphatic glands are not involved. The nipple and areola
are entirely wanting, a glazed, here and there excoriated, partly crusted,
bright, violaceous red, chronically inflamed, infiltrated, rounded patch,
occupying this region. The lesion is firm ; is about two inches in diam-
eter ; has a slightly raised border, and is very sharply defined against the
sound skin. It has an eczematous look, and at first glance would doubt-
less be mistaken for this disease. The sharp line of demarcation, the
border, the infiltration, the glazed surface, and the vivid colour, are, how-
ever, peculiar. Taken between the fingers the infiltration is noted to be
superficial, and is not so deep as one would suppose from the appearance.

It is not necessary to dwell upon the treatment to which the lesion was
subjected ; suffice it to say strong ointments of calomel, tar, and pyrogallic
acid were in turn resorted to without benefit. The pyrogallic acid oint-
ment, from one to three drachms to the ounce, applied continuously,
spread upon a cloth, with the view of producing a caustic effect, was em-
ployed for several months, the crust being removed from time to time
with a poultice. During the time that the ointment was applied and the
lesion was discharging, there was great relief to the itching. Upon the
wound granulating, however, the itching invariably returned, and the
whole breast, moreover, became full and somewhat painful. In view of
the indurated lesions within the gland (without doubt of a cancerous
nature), and the inefficacy of the local treatment to relieve the infiltration,
removal of the gland by excision was proposed, but the patient was un-
willing to have the operation performed.

I have reported these cases to show the clinical features of a disease
which is entitled to special consideration. It must be distinguished from
eczema, which it resembles, and from ordinary cancer, which it is alto-
gether unlike in its earlier stages. It seems to occupy a ground having
the characters of both diseases. The report is interesting as showing the
natural history of the affection. This is peculiar. The course of the
process is emphatically chronic. In both instances, moreover, the pro-
gress of the disease was insidious as well as slow. Nothing of a malig-
nant nature was suspected until after the lapse of five and ten years
respectively. The itching, which eventually became such a marked symp-
tom, was in both cases insignificant until the affection had existed several
years. It may be said not to have manifested itself until after the process
had been well established. In this respect the disease differs decidedly
from eczema, where itching is one of the first signs noted. The circum-
scribed, sharply defined outline of the lesion, and the slightly elevated
border, are also symptoms which do not obtain in eczema. The brilliant
colour of the lesion is striking, and is more marked than in eczema. The
absence of the " eczematous surface," characterized by appreciable dis-
charge or by vesicles, pustules, or puncta, coming and going from time to
time ; and the absence of exacerbations, so usual in eczema, may also be

120

Minor, Experimental Keratitis.

[July

referred to. A point to which attention may also be directed is the infil-
tration, which is firm or even hard, but is not deep-seated. It is rather
superficial. In eczema, on the other hand, it is soft.

The pains coming on later in the course of the disease, and the indu-
rated, lumpy, or knotted lesions within the gland structure, of course
point strongly to the malignant or cancerous nature of the disease, the
existence of which cannot be doubted.

Article X.

Experimental Keratitis: its bearing upon Stricker's theory of In-
flammation. By James L. Minor, M.D., Ophthalmic Surgeon to the
Randall's Island Hospitals, Pathologist and Assistant Surgeon to the N. Y. Eye
and Ear Infirmary.

The favourable reception that has been accorded to Prof. Stricker's
theory of the pathology of inflammation as presented in the International
Encyclopaedia of Surgery, prompts me to publish an article which I pre-
pared a year and a half ago, bearing upon the subject. It was not pub-
lished before because it contained nothing essentially new. I now present
it to add my experiments to those of Senftleben, Councilman, Axel Keye,
Eberth and his pupils, and others. Prof. Strieker has entirely ignored
the results obtained by these investigators, in spite of the fact that his
own methods have been employed in obtaining specimens, and that they
were exact counterparts of those described by himself. These specimens,
when subjected to the influence of dyes, that stain parts before uncoloured,
show changes that are diametrically opposed to his theory. The experi-
ments are neither difficult nor complicated, and one familiar with the mi-
croscope may easily verify them, and prove to himself and to others the
incompleteness of Stricker's work, and the consequent fallacy of his argu-
ment. Without further discussion or excuse the article is presented in its
original form.

During the past year, at the Pathological Laboratory of the Bellevue
Hospital Medical College, under the direction and the kind assistance of
Prof. Welch, I have performed a number of experiments to determine the
origin of pus cells, in inflammation of the cornea of cats, dogs, and frogs ;l
and the results which I invariably obtained are so much at variance with

1 Many of my experiments were made during the spring, the most favourable time,
according to Strieker ; and most of them were performed upon cats, nearly grown,
which he insists upon. I may say, however, that I experienced no difficulty in obtain-
ing his pictures from the corneae of cats of all ages, dogs, and frogs, and at all times
of the year.

1883.]

Minor, Experimental Keratitis.

121

those claimed by some of the eminent pathologists of the present day, that
I feel little hesitation in presenting them ; for they can be' verified by any
careful observer. It is not my purpose to discuss the process of inflamma-
tion, nor will I attempt to enter the field of literature bearing upon the
subject. It will suffice to state in the briefest manner, the two leading
theories concerning the origin of pus cells : first, that of Cohnheim, who
teaches the cell emigration theory, claiming that pus cells are leucocytes
or wandering white blood corpuscles, and denying their origin from other
sources ; and second, that of Strieker, who adopting, with some modifica-
tion, the teachings of Virchow, holds that pus cells are not emigrated
cells, but that they originate from the cells of the inflamed tissue, they
having returned to their embryonal condition, and from these pus cells are
differentiated.

It will not be amiss to give the anatomy of the cornea before studying
the changes that we shall observe in its structure. The anterior boundary
of the cornea is formed by stratified epithelium ; its posterior covering is
a single layer of endothelium. Underneath both the epi- and endothelial
coverings is a thin hyaline layer (Bowman's and Descemet's respectively)
showing fine fibrillation according to some histologists. Between the last
two layers the proper corneal tissue is found. It consists of fine connec-
tive tissue fibres, which run in parallel directions, forming bundles, and
these in turn unite to form laminae that run in various directions, parallel
with the surface, but frequently at right angles to each other, and form
the different layers of the cornea. Between the laminae, and flattened by
them, lie numerous nucleated cells — -the corneal corpuscles — irregular in
shape, and presenting a number of processes, which communicate with ad-
jacent corpuscles, not necessarily between the same laminae. Other cells
— leucocytes — are often seen, and sometimes pigment cells are observed.
These, with the nerve fibres, embrace about all that is to be found.1 I
have found the cat's cornea most satisfactory, because it is easy to lami-
nate, and furnishes a large surface for experiment and observation. Irri-
tation of the centre of the cornea was caused by various substances ; the
most satisfactory were silver nitrate (solid) and potassa fusa, and after in-
tervals varying from twelve hours to a week, the cornea wrere removed
for examination. The agents used for staining were silver nitrate and
gold chloride ; and subsequently the sections so stained were further
stained with haematoxylin or carmine. The corneae to be stained with
silver nitrate, were thoroughly painted with the solid stick while the ani-

1 Strieker thinks that the structure of the living cornea is probably homogeneous, be-
cause differences in structure appear only in post-mortem specimens and as a result
of chemical or staining agents, which he thinks are due to elective affinity of certain
tissue elements to these agents. Although his view conflicts with the view of the
anatomy of the cornea generally accepted, it will not interfere with the question at
issue, i. e., the origin of pus cells.

122

Minor, Experimental Keratitis.

[July

mal was living, and ten minutes later the animal was killed ; the corneas
were removed and washed in distilled water, and placed in acidulated
water, where they remained usually about twenty-four hours, exposed to
diffuse daylight, when they were ready for lamination or section cutting.
Silver stains the intercellular substance a brownish color, and leaves the
corpuscles and their processes uncoloured, so that they appear as clear
spaces in the coloured field. The corneae to be stained with gold were
removed as soon as the animal was killed and washed in distilled water,
and placed in fresh lemon juice, where they remained for five minutes,
when they were taken out and washed again and placed in a half per
cent, solution of gold chloride, in which they remained for half an
hour, more or less, whence they were removed and placed in a reduc-
ing fluid, either acidulated water or, better, Pritchard's fluid (amylic
alcohol 1, formic acid 1, water 100). Here they remained for twenty-
four hours or more, when they were ready for lamination or cutting.
Gold stains the corpuscles and their processes a purplish colour, and
leaves the intercellular substance uncoloured, as clear intervals in
the field — giving a picture which is the negative of that of silver.
Hematoxylin stains the nuclei a deep blue, and the cells a more deli-
cate tint of the same colour. Carmine stains the nucleus a delicate red
or pink, and the remainder of the cell a lighter hue of the same colour.

Let us take a silver-stained cornea, 72 hours after irritation of its centre
with caustic potash. A thin specimen, prepared by lamination, or cutting,
is mounted in glycerine. The staining characteristic of silver is observed,
and nothing peculiar is noticed until we approach the zone of the irrita-
tion ; here we find the spaces corresponding to the corneal corpuscles and
their processes, enlarged and occupied more or less completely by a net-
work of fine brown mosaic tracings, claimed by Strieker to be the outlines
of pus cells which have originated from corneal cor-
Fig- 1. puscles. If the staining is good, cells resembling

pus corpuscles can sometimes be recognized. (See
-2? Fig. 1.) If this specimen is now stained with bamia-
: .. : toxylin, a beautiful picture is presented, and a most

1 - A remarkable change is brought about. The silver

1 ■ staining is unchanged; the corneal corpuscles are

'W^^^^S^ now to be seen, they are of a bluish tint, and their

nuclei are coloured a deeper hue ; while the pus cells,
with their often horseshoe-shaped nuclei (a peculi-
cat's cornea 72 hours it f h M blood-corpuscles of the cat\ are

after central irritation with. J r "

caustic potash, stained with stained a dark blue. "We can now study the ap-
aUTer nitrate, a intercel- pearance the arrangement, and the relation of parts

lular substance of a brown- .

ish colour, b. " Corneal with an intelligence impossible before this distin-
spaces," occupied by deli- guishing difference was produced. We can readily

cate mosaic tracings, the

outlines of pus cells. map out zones, differing essentially from each other

1883.1

Minor, Experimental Keratitis.

123

in appearance. The first zone embraces the periphery of the cornea,
in which the corneal corpuscles are healthy and unchanged, and where
there is an abundance of pus cells, many of which are of the ordinary
appearance, with horseshoe-shaped nuclei, while others are drawn out
as small rods, with elongated nuclei. In reference to the position of the
pus cells, most of them occupy the spaces conjointly with the corneal
corpuscles, but many of them lie in the intercellular tissue; and it is here
that the rod-shaped pus cells are chiefly found. Some of the rods have one
extremity in a corneal space, while the other is embedded in the inter-
cellular substance. In passing through the interspaces of the fibrous tissue
of the cornea, the leucocytes assume the size and shape of the channels they
traverse thus giving rise to the rod-shaped form. The second zone lies
between the corneal periphery and the central eschar ; here the corneal
corpuscles are unchanged, and pus cells are scanty or absent. The third
and last zone embraces the central eschar and the immediately adjoining
tissue.

The eschar, which has not been changed by the ha3matoyxlin, is a
brownish granular mass, devoid of structure. The parts adjacent to this
show the intercellular substance to be diminished, and encroached upon
by enlarged corneal spaces. The corneal spaces are in most instances
filled with pus cells, containing the horseshoe-shaped nuclei observed in
other zones; but in those spaces not fully occupied by pus cells, the out-
lines of non-nucleated shrunken (dead) corneal corpuscles can be recog-
nized. And in some instances it is possible to detect the body of a dead
corneal corpuscle beneath an almost complete bridge or layer of parallel
rod-shaped pus cells — the intervals between the rods are sufficient to allow
a clear distinction of parts beneath. As we approach the middle zone
from this point, it will be noticed that the
pus cells become less numerous, and that Fig. 2.

the corneal corpuscles change at once to the ~g
normal condition, or present certain changes,

that will be presently referred to. (See — "~
Fig. 2.) It is evident from a study of the ^z°-ci\: ' -

above description and the accompanying cut, : / ~

that the pus cells did not originate from the
corneal corpuscles. That leucocytes possess
a remarkable power of emigration, has been
incontestably proven by Cohnheim and
others ; and their immigration accounts for
the presence of pus cells in our specimen,

in a far more satisfactory manner than can Same sPecimen after staining with

- J ■ liaematoxylin. Both A and B the

any other process. Their abundance in the same' as in Fig. l ; b, in this figure,
peripheral zone is plainly due to emigration is seen t0 be occupied by corneal cor-

e . . puscles (a) and pus cells, „both round

trom adjacent conjunctival and scleral ves- ^ and rod-shaped (c).

124

Minor, Experimental Keratitis.

[July

sels — both of the latter tissues being loaded with them. The great number
about the eschar is also to be explained by immigration — for here we have
a denuded surface exposed to the conjunctival membrane, which furnishes
a bountiful supply — the conjunctiva itself being hyperaemic or inflamed.
The arrangement of the rod-shaped cells is characteristic and striking,
the rods in many instances form radii with the eschar as a centre, a fact
which clearly indicates that they had entered here, on their passage into
the corneal tissue.

It was stated above that changes sometimes occur in the corneal cap-
sules surrounding the eschar. This change consists in sending out delicate
thread-like processes or off-shoots (regeneration spears of the Germans),
the direction of which is always towards the eschar. And at some points
the extremities of two spears or processes will approach each other and
coalesce. Here a circumscribed enlargement is formed, from which new
spears may spring. Other individual spears will terminate in bulbous
enlargements, which present secondary processes. This proliferation of
corneal corpuscles is plainly not pus formation. It is a regenerative pro-
cess by which the living corpuscles attempt to repair the destruction
caused by the caustic, by forming new corneal corpuscles.

The specimen just studied was selected because it illustrated all of the
conditions which it was desired to show. It is exceptional to find one pre-
senting all of these appearances. They will vary according to the degree
of irritation, and also according to the time at which they are examined.
When the cornea is moderately irritated, without an abrasion of its sur-
face, the number of pus cells about the eschar will be small, while they
will abound in the periphery of the cornea, and the regeneration spears or
processes will be numerous. Whereas, if the irritation has been severe,
and if there is a loss of substance, such as follows free cauterization ; the
pus cells about the eschar will be abundant, and greatly in excess of those
in the peripheral zones, and the regeneration spears will be slower in
making their appearance. The corneal corpuscles surrounding the eschar
in this instance are overcome by the pressure of leucocytes, which force
their way through and crowd themselves into the adjacent tissue ; and it
is only after this pressure is relieved by sloughing of the parts that the
regenerative process shows itself. The regeneration spears were not ob-
served in any specimen earlier than thirty-six hours after cauterization.
They are seen to greatest advantage in gold-stained specimens. (See
Figs. 3 and 4.)

As a summary, I may say, that Strieker rests his conclusions upon the
appearances presented by silver-stained specimens ; that he is correct in
claiming that the mosaic tracings indicate the outlines of pus cells ; but
that he is wrong in his-conclusions as to their origin ; and that he will
continue to be mistaken so long as he confines himself to a single staining
(silver). He limits his study to the eschar and its immediate vicinity,

1883.] Bruen, Enlargement of the Bronchial Glands.

125

Figs. 3 and 4.

Fig. 3. Cat's cornea, 86 hours after central Irritation with caustic potash, stained with gold
chloride, and showing the so-called regeneration spears.

Fig. 4 Cat's cornea, 86 hours after central irritation with caustic potash, stained with silver,
showing regeneration spears.

All of these specimens were taken from the zone surrounding the eschar.

because silver-stained specimens show changes in no other locality. We
claim to have established the immigration theory ; because the pus cells
are similar in appearance to the white blood-corpuscles (both have horse-
shoe-shaped nuclei in cats) ; they can be traced from the corneal periphery
to the point of irritation; and having also gained access to the corneal
tissue through the eschar, they are most abundant immediately around
this centre, where we can still recognize dead, but intact, corneal cor-
puscles. The corneal corpuscles show signs of proliferation, some time
after the cell immigration has set in ; and this proliferation gives rise, not
to pus cells, but to new corneal corpuscles, and they are strictly limited to
the zone surrounding the dead corneal corpuscles ; whereas leucocytes, or
pus cells, in abundance, can be found in various parts of the eornea, at a
distance from this point.
New York, April, 1883.

Article XI.

Enlargement of the Bronchial Glands as a Cause of Irritation of
the Pneumogastric Nerve. By Edward T. Bruen, M.D., Physician
to the Philadelphia Hospital, and Demonstrator of Clinical Medicine in the
University of Pennsylvania.

• There are certain disorders affecting the rhythm of the respiratory
functions which approach the asthmatic type of dyspnoea, and yet which
never , result in a paroxysm of asthma. The function of the pneumogas-
tric nerves is governmental chiefly of the rhythm of the respiratory action.
The tenth nerve contains both accelerator and inhibitory fibres, and Rosen-
thal declares the respiratory centre to be the seat of two forces of con-

126

Bruex, Enlargement of the Bronchial Glands.

flicting nature, the one labouring to generate respiratory influences, the
other tending to offer resistance to the generation of these impulses. The
alternate victory of the one over the other leading to the rhythmic dis-
charges of force and the regulation of respiration as we find it in health.
Hence, when the vagi are divided the central resistance is increased,
owing to the absence of the diminishing effect of the usual afferent im-
pulses. In consequence the respiratory impulses take a longer time in
gathering sufficient head to overcome the increased resistance, and there-
fore the respiratory acts are less frequent, though the discharge, when it
does occur, is proportionately more forcible. Stimulation of the divided
vagi, on the other hand, by increasing afferent impulses, and so diminish-
ing central resistance, renders discharges of accelerator force more fre-
quent.

We also know that the superior recurrent laryngeal nerve is composed
mainly of inhibitory afferent fibres, by the stimulation of which respira-
tion can be brought to a standstill, the respiratory apparatus remaining as
at the close of expiration. This effect can also be produced by first ex-
hausting the neurility of the accelerator afferent fibres of the main trunk
of the pneumogastric nerve, which permits the inhibitory fibres to obtain
the controlling influence, and thus reduces or stops the respiratory action,
just as when the superior laryngeal branches are stimulated. Now, pres-
sure within the chest, exercised upon the pneumogastric nerve or its
branches which supply the bronchial tubes, may excite irritation of the
afferent nerve thereby reducing central resistance, and the accelerating
impulses may be discharged more frequently.

We meet clinically four varieties of asthma. One the common form of
spasmodic asthma often associated with or preceded by emphysema and
bronchitis, attended by spasm of the bronchial tubes, and other familiar
phenomena. A second form is known as cardiac asthma, often observed
in association with emphysema. A third variety is the asthma which is
sometimes associated with the forms of Bright's diseases of the kidney
called uremic asthma. This variety is dependent upon a spasm of the
arterioles of the lungs, induced by the direct impression of the circulating
undepurated blood upon the governing vaso-motor centres. This form is
not associated with spasm of the bronchial tubes, for auscultation can fur-
nish satisfactory evidence that air enters and passes from the bronchial
tubes without hindrance. This form of asthma once thought of, is easily
recognized by being associated with dropsy or arterial thickening, with
accentuated second sound or other evidences of renal disease.

A fourth form of asthma may be more correctly termed a rhythmic dis-
order of respiration dependent upon pneumogastric irritation.

In the Philadelphia Medical Times of October 11, 1879, maybe found
reported a case of aneurism of the ascending aorta, giving origin to a
tumour about the size of a hen's egg. The tumour was filled with dense

1883.] Bruen, Enlargement of the Bronchial Glands.

127

laminated clot. Passing over the inferior surface of the tumour was the
pneumogastric nerve, which was compressed between the' tumour and the
bodies of the vertebra?. In this case there were paroxysms of dyspnoea,
at first very light ; merely noticed as spells of shortness of breath ; but
they rapidly increased in severity and frequency, pari passu with the
enlargement of the tumour, until they occurred almost daily. In addition
to this paroxysmal dyspnoea there was constant dyspnoea from pressure of
the aneurism on the trachea and bronchial tubes. The emphatic observa-
tions in the case were the asthmatic paroxysmal nature of respiratory
disturbance, its very mild onset amounting only to shortness of breath,
with coughing, and the sudden aggravation of the symptoms which pre-
sumably occurred because of the sensitiveness of the nerve to the influence
of non-aerated blood.

In the hysterical state functional disorders of respiration are very com-
mon, apparently dependent upon reflex irritation of the pneumogastric
nerve from some disarrangement of the sexual organs. Exclusive, how-
ever, of reflex pneumogastric irritation from this cause, the design of this
paper is to invite attention to a group of symptoms presented by a class of
cases which may possibly be explained as having their origin in intra-
thoracic pneumogastric irritation.

Case I In the early part of the winter of 1880 an unmarried lady,

about 24 years old, applied to me for advice. She was of a distinctively
scrofulous habit, testified by the facies, by a history of suppurating gland-
ular tumours in the neck, suppuration in the axillary glands during ado-
lescence, and a susceptibility to catarrh. Enlarged tonsils, laryngitis,
bronchial catarrh, loss of flesh and appetite, with feelings of lassitude
were the general symptoms.

The special phenomena were shortness of breath, inability to thoroughly
inflate the lungs, and pain over the back to the right and left of the first
and second dorsal vertebra;, mostly on the right side. There was a trouble-
some metallic laryngeal cough during most of her illness, with some
expectoration of glairy mucus.

There was no fever ; she complained of substernal fulness or pressure.
The physical signs were normal resonance over the lungs anteriorily, in
the axilla?, and over the bases posteriorly. There was impaired reso-
nance in the inter-scapula region on both sides of the vertebra? extending
from the first to the third dorsal vertebra?, especially marked on the right
side. The respiratory murmur was everywhere normal, save that in the
area of dulness there was feeble bronchial breathing, and on the right
side it acquired a whistling tone. Over the left apex, in the inter-scapu-
lar region, the respiratory murmur was positively feeble. Yocal resonance
was not increased at any part of the chest.

Case II. — A girl of 18, who enjoyed apparently good health, with
rosy cheeks, regular in menstrual habit, not at all nervous, as the phrase
is popularly understood, consulted me for the following symptoms : Pain
in the back over the inter-scapular region on the left side, near the second
dorsal vertebra. Cough, which had been troublesome for two months
with shortness of breath. The want of breath manifested itself in a pecu-
liar way. If desired to breathe, during an examination of her chest, she

128

Beuen, Enlargement of the Bronchial Glands. [July

was able to draw a few deep inspirations, and then was obliged to draw
them in a much more shallow way, or she said she would have a spell re-
sembling asthma. There was a moderate degree of vesiculotympanitic
resonance over the lungs; no dulness at any point. Respiratory murmur
was feeble over the upper lobes, more distinct over the lower. The
rhythm of respiration was jerky, expiration low-pitched and indistinct, in-
spiration shortened. Paroxysms of shortness of breath would occur on
exertion, producing a sense of suffocation, never occurring at night, or
coming on suddenly. 'There was constant feeling of fulness and subster-
nal tightness. The family history of this girl indicated a scrofulous in-
heritance. Her father suffered from Pott's disease of the spine, and two
aunts had died of pulmonary phthisis.

Case III. — A young man, 22 years of age, who had been under treat-
ment for a general bronchial pharyngeal anjd nasal catarrh for eighteen
months. He came to me in the spring of 1882 with the same subjective
symptoms. There was a general deficiency of nervous tone induced by a
course of assiduous study. Family history good but diathesis scrofulous,
so that it was fair to infer that scrofulous changes might develop when the
system was reduced. Dyspncea was also a symptom and was of the type
described in Case II. There was marked general relaxation with catarrh
of the respiratory mucous tract.

It is perhaps well to observe that in each of these cases the heart was
sound, but its rhythm was more or less modified by an increase in the
rapidity of its action. It is unnecessary to epitomize other cases, though
at least ten instances of a similar nature appear on my records.

An analysis of the symptoms will not fail to show that respiratory inner-
vation was seriously at fault in each case. Enlargement of the cervical
chain of lymphatics can be traced to catarrh of various parts of the
upper respiratory tract, and this is particularly the case in the scrofulous,
or in those artificially reduced to this state, or in children who are badly
fed and lodged.

1In cases of epidemics of influenza the bronchial glands have been de-
scribed as undergoing enlargement, occasioning more positive physical
signs than those mentioned in this paper. In hay-asthma the type of
breathing suggests pneumogastric irritation and invites an examination of
the bronchial glands, as affording a new avenue of therapeutical attack.
Guineau de Mussy has written in some detail of the enlargement of these
glands in pertussis, and foreign literature contains much that is interesting,
but which has been little dwelt upon by American writers. Enlargement
of the bronchial glands has not been frequently noted in cases of persistent
catarrh of the bronchial passages as a cause of respiratory embarrassment
and consequent bronchial and pulmonary changes.

2But it is evident that enlargement of the bronchial glands can readily

1 A Contribution to the History of Influenza, by Dr. Guiteras and Dr. J. William
White. A valuable paper with especial reference to Enlargement of the Bronchial
Glands ; Phila. Med. Times, April 10, 1882.

2 Sappey, Anatomie descriptive. An excellent description of the relations of the
nerves to the other structures at the root of the lungs.

1883.] Bruen, Enlargement of the Bronchial Glands.

129

affect the pneumogastrics, since these nerves pass before and behind the
oesophagus and are environed by these glands. The enlargement of the
bronchial glands may be acute, subacute, or chronic ; the symptoms can
therefore be manifested for a variable period of three to many weeks.

!The effect of bronchial enlargement upon the lung through the pres-
sure on the pulmonary plexus is full of interest. Congestion, collapse,
pneumonia have each been described. Reference to the literature of the
subject can be so readily made that I forbear to lengthen this article by
reproducing further changes in detail. In only one of my cases was there
serious pulmonary congestion.

The physical signs on auscultation and percussion by which enlargement
of the bronchial glands can be recognized are applicable chiefly when the
enlargement is considerable.

The physical signs by percussion T as demonstrated by M. Guineau de
Mussy, consist in percussion over the spinous processes of the cervical
vertebrae, the course of the trachea. Following this line in the healthy
subject, a distinct tubular sound is elicited by percussion down to the
point of bifurcation of the trachea at the level of the fourth dorsal verte-
bra. Opposite the fifth and downward we get the lower-pitched pulmon-
ary resonance. When the tracheal and bronchial glands are enlarged,
the tubular sound over the upper dorsal vertebra? is replaced by dulness,
which may contract sharply above with the tracheal and below with the
vesicular resonance. Dulness on percussion may easily be absent since
the inter-scapular region is covered by thick parietes.2

Auscultation gives variable results, which have already been suffi-
ciently described in the narrative of the cases. The usual physical signs
of congestion of the lungs may be met with when there is associated pul-
monary engorgement.

The difficulty in the diagnosis of such cases consists in separating
them from cases of early phthisis. One must rely mainly on the absence
of the combination of physical signs required to render the presence of
incipient phthisis certain. These are imj aired percussion resonance,

1 Guy's Hospital Reports, vol. v. 1859, on Destructive Changes in the Lung from
Disease of the Mediastinum invading- or compressing the Pneumogastic Nerves or
Pulmonary Plexus. Lancet, March and April, 1878, S. P. Irvine on Collapse, Emphy-
sema, and Destructive Pneumonia in Association with Tumours compressing the
Bronchi. Ziemssen's Cyclopaedia of Med., vol. iv., Stenosis of Trachea and Bronchial
Tubes, by Riegle. Ogle, Effect of Aneurismal Pressure ; London Path. Transaction,
vol. xvii. Edinburgh Med. Journal, 1850-1851, Effects upon the Lung of Bronchitis
and Bronchial Obstruction.

2 Rilliet and Barthez, Maladies des Enfants. Speaking of adenopathic bronchique, or
tuberculization tics ganglions bronchiques, "Dans un grand nombres d'affections
chroniques et dans beaucoup de congestions aigues des organes thoraciques, on con-
state des modifications du bruit respiratoire souvcmt limitees a- un seul co-e ou m§me
a un seul lobe sans lesion locale appie.-iable. Rien n'est plus commun dans la phyma-
tose dans la rougeole, dans la coqueluche."

No. CLXXL— July 1»83. 9

130

Bruen, Enlargement of the Bronchial Glands.

[July

some form of bronchial breathing, possibly fine moist rales and increased
vocal resonance. The last two physical signs are not present in cases of
bronchial enlargement. Pain in the back and disturbance of the respi-
ratory rhythm are not often present in phthisis. Hysteria, uterine, or
spinal disorder may be eliminated by careful examination.

Finally, the beneficial results of treatment may be appealed to in order
to sustain the pathological hypothesis of the etiology of the cases. Coun-
ter irritation must be made a principal feature of the therapeutics. It
can be effected by painting a broad band 5 x 10 inches down the inter-
scapular space, using the following formulas : —

R. 01 tiglii,

Ether, sulph., gij.

Tr. iodinii, sjv.
M. Sig. — Use as a paint.

This produces pustulation, and is one of the most efficient means of
counter-irritation. It must be applied and allowed to dry before the
clothing is assumed, so that the croton oil may not be transferred .where
it is not desired. In place of the above, an ointment may be used of the
biniodide of mercury, sixteen grains to the half ounce of vaseline, rubbed
into the same region. After producing vesication, it should be suspended,
and again resumed after the skin has peeled off. I have sometimes found
it necessary to prolong treatment for a year. Benefit may be expected
in two or three weeks, and the average duration about ten weeks to three
months, unless there be marked scrofulous diathesis. Internally, the
most important measure is the continued use of calomel, one-twentieth to
one-fiftieth of a grain. The bichloride or the protiodide of mercury, in
corresponding doses, if, for any reason, calomel is contraindicated. LugoPs
solution may be prescribed, but the digestive apparatus cannot often tole-
rate it. When the cough is severe, the muriate of ammonia can be com-
bined effectively with the bichloride of mercury. Cod-liver oil, the syrups
of the phosphates and small amounts of iron are useful. The disorder
of the respiratory rhythm is only very gradually remediable as the cause
of pneumogastric irritation is removed. Meanwhile the continuous use
of small doses of sulphate of strychnia?, the one-fiftieth or the one-hun-
dredth of a grain as a respiratory stimulant, is satisfactory. It may be
conveniently prescribed in the same pill with the calomel. When asth-
matic dyspnoea is prominent, belladonna internally or stramonium ciga-
rettes can be ordered. Arsenic may be held in reserve. Opiates and
bromides, to say the least, produce only a palliative effect. Finally, much
benefit may be derived through the influence of change of climate upon
nutrition..

1883.]

Fletcher, Experiments on Serpent Venom.

131

Article XII.

A Study of some recent Experiments on Serpent Venom. By Robert
Fletcher, M.R.C.S.E., Washington, D. C.1

The destruction of life from the bites of poisonous serpents is so exten-
sive, the danger so insidious, and the fatal result follows so speedily, that
at all times the subject has been one of especial interest and importance.
The medical journals of India, as might be expected, abound with details
of cases, of tests of supposed antidotes, and of experiments to determine
the mode of action of the venom. Sir Joseph Fayrer states the average
mortality from serpent-bites in India to be fully 20,000 annually. In
1869 the returns were obtained, through official sources, from a large part
of India with unusual care and accuracy. In a population of nearly
121,000,000, representing an area of less than half the peninsula of Hin-
dostan, the deaths were 11,416, or nearly one in 10,000.

Of these deaths, there were caused by —

Cobra 2,690

Krait (Bungarus ceruleus) . . . 359

Other snakes ..... . 839

Unknown snakes . . i . . - - . 6,922

\No details ........ 6U6

11,416

The number of deaths from " unknown snakes," which seems surpris-
ingly large, is easily understood when it is remembered how general
among the natives is the custom of sleeping on the ground. A person is
bitten, and the snake escapes unseen in the darkness.

In 1880, 212,776 poisonous snakes were killed and paid for ; and in
1881, 254,968.

Even in Europe, the number of accidents from snake-bite is very large.
In one department of France, La Haute-Marne, the government paid, in
six years, for the destruction of 17,415 vipers.

Before describing the recent researches of Lacerda, of Gautier, and of
Weir Mitchell, which is more especially the object of this paper, it will
be useful to make a brief summary of the most important investigations
which had preceded them.

The first writer who published his experiments with serpent venom was
Francisco Redi, an Italian. His observations on the viper appeared at
Florence, in 1664. 2 His work was far surpassed in value by that of his
countryman, Felix Fontana, whose " Richer die jilosojiche sopra it veneno
della vipera" was -published at Lucca, in 1767. This classic, work in
toxicology has been translated into many languages. Fontana's experi-

1 Read before the Philosophical Society of Washington, May 19, 1883.

2 Osservazioni intorno alle vipera. Fr. Redi, Firenze, 1664.

132

Fletcher, Experiments on Serpent Venom.

[July

ments were G000 in number, and are admirable for the patient care and
fidelity with which they were conducted. His knowledge of physiological
chemistry was, of course, limited, but many of his conclusions have been
confirmed by modern researches.

In 1845, Prince Lucien Bonaparte analyzed the venom of the viper,1
and discovered an active principle which he named viperine or echidnine.
This was the first chemical analysis which had been made of serpent
venom.

But the most important contribution to our knowledge of the subject is
to be found in the elaborate series of experiments with rattlesnake venom,
conducted by Dr. Weir Mitchell, of Philadelphia. His first account of
them appeared in the Smithsonian Contributions to Knowledge for 18G0,
forming 117 quarto pages,1 and his second essay appeared in the New
York Medical Journal for January, 18G8.3 The earlier work begins witli
a full account of the anatomy of the head of crotalus, including the his-
tology of the poison glands, and the action of the muscles concerned in
the act of striking. This is followed by researches into the physical and
chemical characteristics of the venom, and into the manner in which it
acts upon cold-blooded and warm-blooded animals. Its effects on man,
and the action of the principal known antidotes are next discussed, and
an excellent bibliography completes the work. In his second essay, Dr.
Mitchell announced some corrections of his views, as the result of further
experiments. A brief account must be given of some of his more im-
portant conclusions.

Rattlesnake venom is a glutinous substance resembling a thick solution
of gum acacia, in colour varying from a pale emerald-green to an orange
or straw colour. Its specific gravity is about 1041. When completely
desiccated it resembles dried albumen. Dr. Mitchell frequently tasted
the venom and never perceived any pungency or acridity, or benumbing
of the tongue, qualities which have been often attributed to it, as well as
to viper venom. Its reaction was always acid. It is unnecessary to give
an account of the investigations made into its chemistry, as they are super-
seded by Dr. Mitchell's recent experiments. The toxicological effects of
crotalus venom were the subject of a long series of experiments, which are
fully detailed. The conclusions may be briefly stated.

Venom is harmless when swallowed. I. Because it is incapable of
passing through mucous surfaces. II. Because it undergoes some change

1 Ricerche chimiche sul velleno della vipera, pel Principe L. L. Bonaparte (letto in
occasione della qninto unione degli Scienziati Italiani, tenuta in Lucca l'anno, 1843).
Gazzetta toscana delle scienze medicoflsiche. Firenze, 1843, p. 169.

2 Researches upon the Venom of the Rattlesnake, with an Investigation of the Ana-
tomy and Physiology of the organs. concerned, by S. Weir Mitchell. Smithsonian Con-
tributions to Knowledge, Washington, 1860, 4to. 117 pages.

3 Experimental Contributions to the Toxicology of Rattlesnake Venom, by S. Weir
Mitchell, New York Medical Journal, 1868. Also, Reprint.

1883.]

Fletcher, Experiments on Serpent Venom.

133

in the process of digestion which allows it to enter the blood as a harmless
substance, or to escape from the intestinal canal in an equally innocent
form. The rectum of the pigeon does not absorb the venom, and it pro-
duces no effect on the conjunctiva of animals.

The venom passes by endosmosis through serous membranes with great
rapidity. Dr. Mitchell "contrived to place a loop of the peritoneum of a
chloroformed rabbit under the microscope ; the circulation was beautifully
exhibited, and, upon a drop of venom being deposited on the membrane,
after the lapse of a minute, a sudden eruption of blood-corpuscles took
place at the bifurcation of a capillary vessel followed by similar occur-
rences in other portions. The same phenomena appeared on the bared
surface of muscles thus poisoned. This action, together with the defect
of coagulability of the poisoned wound, accounts for the excessive hemor-
rhage about fang wounds.

In acute poisoning, where death rapidly ensues, the coagulability of the
blood is not generally impaired, but where the symptoms are prolonged,
the blood, after death, does not coagulate. The blood globules, according
to Mitchell, are unaltered in venom poisoning, though he observed, in a
few chronic cases, some disintegration of the edges. I shall recur to this
point when speaking of Lacerda's and Halford's views. The cause of
death, in acute poisoning in warm-blooded animals, is the cessation of
respiration from paralysis of the nerve centres. The heart is enfeebled
but not paralyzed. In chronic or secondary poisoning, the rapid decom-
position of the blood and of the tissues locally acted upon, leave no doubt
that serpent venom is a septic or putrefacient poison of astounding energy.

In his earlier experiments, Dr. Mitchell was led to believe that a rattle-
snake's bite was fatal to itself, or to a fellow-crotalus. In his second
essay, he comes very decidedly to the opposite conclusion. To this also
reference will be made in connection with the poisonous snakes of India.

It is evident that, in experiments with venom, it will not do to depend
upon the bite of the snake. If death do not follow, the escape may not
be due to the virtue of an antidote but to the poison-gland having been
recently emptied. Dr. Mitchell forced his snakes to bite the edge of a
saucer into which the poison would drip. All his experiments were made
by inoculating the venom thus obtained. From two to four drops are
usually discharged at one bite, though fifteen drops were obtained from a
snake which had been kept a long time in a box.

Dr. Mitchell's experiments as to antidotes resulted in the conviction of
the absolute uselessness of the sulphites and hyposulphites, and the dis-
covery that carbolic acid had no, value as a true antidote, though it de-
layed a fatal result by interfering with the local circulation. This it does
by its power to coagulate albumen. He mentions as a curious fact that
some of the pigeons inoculated with venom and carbolic acid died with all
the symptoms characteristic of poisoning by the latter powerful agent.

134

Fletcher, Experiments on Serpent Venom.

[July

A case was, however, recently reported from Algeria1 in which a French
soldier was bitten by the Naja viper ; alarming symptoms followed, but
the application of a caustic, saturated, solution of carbolic acid, saved the
man. Dr. Viaud-Grand-Marais also recommends this remedy.

It had been announced by Dr. Gilman,2 in 1854, that serpent venom
would destroy vegetable life. Dr. J. H. Salisbury made a similar declara-
tion.3 Their experiments were few, ill-guarded, and inconclusive, but
Dr. Mitchell pursued the inquiry with all necessary precautions, and found
no ground whatever for such a belief. I may add that a French surgeon,
who has published his researches into the poison of the viper, M. Viaud-
Grand-Marais,4 positively denies that it has any effect on plants.

The late Mr. Darwin made some experiments with cobra poison on
Drosera. He says : u I felt sure that the leaves were killed ; but after
eight hours' immersion they were placed in water, and, after about forty-
eight hours, they re-expanded, showing that they were by no means
killed. The most surprising circumstance is that, after an immersion of
forty-eight hours, the protoplasm in the cells was in unusually active
movement. . . . Hence 1 cannot doubt that this poison is a stimulant
to the protoplasm."5

The next important work, following Dr. Mitchell's essays, is that of
Dr. Joseph Fayrer, of Calcutta, now Sir Joseph Fayrer, President of the
Medical Board of the India Office. It is entitled : " The Thanatophidia
of India, being a description of the Venomous Snakes of the Indian Penin-
sula, with an account of the Influence of their Poison on Life, and a
Series of Experiments. London, 1872. Imp. folio, with thirty-one plates."
This is a superb work, revelling in all the luxury of finest paper, blackest
print, and beautifully coloured plates. The experiments were continued
through three years, and, though chiefly made upon cobra venom, include
the effects of some other poisonous serpents. There are twenty-one fami-
lies of Indian snakes, of which seventeen are innocuous. The four poison-
ous families are divided into two groups. I. Colubrine, which includes
the Elapidse and Hydrophidce. II. Viperine, including the Viperida3 and
Crotalidae. The experiments were made upon the ox, horse, goat, pig,
dog, cat, civet, mongoose, rabbit, rat, fowls, kites, herons, fish, harmless
snakes, poisonous snakes, lizards, frogs, toads, and snails. As regards

1 Dela morsure dela vipereNaja en Algerie, etde son traitement par l'acide phenique.
Par M. Jacquemet. Rec. de mem. de me j. mil. etc. Paris, 1881, 3e ser. 226.

2 On the Venom of Serpents. B. J. Gilman, St. Louis Med. and Surg. Journal,
1854, p. 25.

3 Influence of the Poison of the Northern Rattlesnake (Crotalus durissus) on Plants.
J. W. Salisbury, N. York Journ. Med. 1851, U. S., XIII. p. 337.

* Diet, encyclop. des sciences medicales, 1881, sub voce Serpents venimeux.

5 On the Nature and Physiological Action of the Crotalus-poison as compared with
that of JSfaja tripudians and other Indian Venomous Snakes, etc. By T. Lauder Brun-
ton and J. Fayrer. Proc. Roy. Society, 1875, No. 179. Also, Reprint.

1883.]

Fletcher, Experiments on Serpent Venom.

135

these creatures, he arrived at the following conclusions : Snake poison
acts with most vigour on the warm-blooded animals ; birds succumb very
rapidly ; a vigorous snake can destroy a fowl in a few seconds. The
power of resistance is generally in relation to the size of the animal, though
not altogether so; cats, for example, resist the influence of the poison
almost as long as dogs three or four times their size. Cold-blooded ani-
mals also succumb to the poison, but less rapidly. Fish, non-venomous
snakes, mollusca, all die. After death from cobra poison, the blood coagu-
lates, but generally remains fluid after viperine bites.

Fayrer's experiments confirm those of Weir Mitchell, that poisonous
snakes are not injured by their own venom or that of other poisonous
snakes. He found, however, that the smaller and less poisonous varieties
were affected by the bite of the cobra or daboia, though very slowly.
From his description of the symptoms in these cases, it may be inferred
that the local injury was followed by blood-poisoning, probably due to the
development of micrococci.

In one important respect, Fayrer's conclusions differ from Mitchell's.
He asserts very positively that snake-poison is deadly when applied to a
mucous membrane, to the stomach or conjunctiva. He goes on to state
that the blood of an animal, dead from snake-poison, is itself poisonous ;
if injected into another animal, death ensues, nevertheless the fowls and
pigeons killed in his experiments were greedily sought for by his attend-
ants, who ate them with impunity. As the process of cooking cannot
destroy the deadly qualities of venom this fact strongly militates against
Fayrer's theory. He found that venomous snakes, though not at all affected,
or very slightly, by snake-poison, are yet very susceptible to other poisons,
such as strychnia or carbolic acid. The latter destroys them very rapidly,
and they seem to have a great aversion to it.

Sir Joseph Fayrer tested every known or asserted antidote, but the
results were, in every case, unfavourable. The ligature, excision, and
general treatment seemed to give the only chance for life, and they were
often powerless. It seems reasonable, however, that experiments upon
such small and susceptible animals as fowls and pigeons should not be held
as conclusive against the possible virtue of an antidote, in poisoning of
large mammals, including man.

Having thus rapidly sketched preceding investigations and discoveries,
we come to those of recent date.

Dr. J. B. de Lacerda, Director of the Physiological Laboratory of the
National Museum of Rio Janeiro, has been, during the last ten years, ex-
perimenting with the venom of Brazilian snakes, especially witli that of
Bothrops jararacassu, a serpent which closely resembles its congener, the
JNorth American crotalus, in the intensity of action of its venom. Dur-
ing that time, he has made several communications to the French Academy
of Science.

136

Fletcher, Experiments on Serpent Venom.

[July

In 1872, Lacerda announced that he had discovered " figured ferments"
in the venom of serpents.1 He placed a drop of rattlesnake venom under
the microscope and saw the production of spores take place. The spores
increased by scission and by internal nuclei. This has not been con-
firmed by further experiments.

The blood of a poisoned animal presented the following phenomena:
the red corpuscles began by presenting little shining points which increased
until the globule broke down, and was replaced by numerous ovoid cor-
puscles, very brilliant, and possessed of oscillatory movements. The blood
obtained from animals which had died from the serpent's venom, when
injected into others, hypodermically, invariably produced death in a few
hours. It will be remembered that Mitchell did not observe any change
in the red blood corpuscles to any marked extent.

Further experiments were made in 18792 and 18803 by Lacerda,
assisted by Dr. Couty, a pupil of Claude Bernard. This time they em-
ployed the venom of the Bothrops jararaca, which is held to be less
potent than that of the jararaeassu, in order to test the effect of local in-
jections. These were made in all the tissues of the body, in the muscles,
the heart, the pleura, the brain, the intestines, the stomach, and, by means
of a laryngotracheal sound, in the substance of the lungs.

Wherever injected, unless there was vascular rupture, or an antecedent
wound, there were no signs of the poison having entered into the blood.
On the contrary, local evidences of inflammation were invariably produced,
often of great intensity, such as phlegmonous abscess, meningo-encepha-
litis, acute pleurisy or pneumonia.

Of all the tissues, the lungs seemed to be the most sensitive to the
effects of the venom, and death ensued almost as -rapidly as when the
injection was made into the blood. The intestines were very slow to ab-
sorb the poison, the stomach, above all, being almost insensible to its
effects.

In 1881, a continuation of these experiments was practised on mon-
keys and frogs. The effect on monkeys, whether the poison were injected
into the veins or into the tissues, was more rapid than on the dogs which
had been the subjects of the previous experiments ; while, as was to be
expected, the effect upon frogs was proportionately slower. The fatal
dose for a monkey, compared to that requisite for a frog, regard being had
to their proportionate weight, was about 1 to 1000.

But the most interesting of Lacerda's discoveries was reported to the
French Academy of Sciences in September, 1881. After proving the in-
efficiency of various supposed antidotes, such as perchloride of iron, borax,
tannin, and other substances, he found that the permanganate of potas-

1 Comptes rendus, Acad. d. sc., Paris, 1877, lxxxvii. 1093-1095.

2 IbiJ., 1879, 372-8. 3 Ibid., 1880, 549.

1883.]

Fletcher, Experiments on Serpent Venom.

137

s:um produced very remarkable results. He obtained his supply of poison
by forcing the bothrops (the more deadly variety), to tiite cotton-wool,
and the venom which poured out upon it was dissolved in eight to ten
grammes of distilled water. A syringeful of this solution was injected into
the cellular tissue of the thigh or groin of a dog. In from one to two
minutes after, the same cpjantityof a filtered one per cent, solution of per-
manganate of potassium was injected. The dogs, examined the next day,
exhibited no evidence of injury, except a trifling local irritation at the
point of injection. Nevertheless, this same solution of venom, injected
into the tissues without the counter-poison, produced great swelling, ab-
scesses, and extensive loss of substance.

Lacerda next injected the poison into a vein, and here again, the per-
manganate was found to be of signal efficacy. Out of 30 experiments,
two only were unsuccessful, the failures being attributed to the bad con-
dition of the dog in one case, and to the too great delay in administering
the remedy in the other. A solution was made in 10 grammes of water
of the venom obtained from 12 to 15 bites of a bothrops. Half a syringe-
ful of this was injected into a vein and 2 c. c. of a one per cent, solution of
the permanganate was injected, half a minute later. Beyond a slight
agitation and quickening of the pulse, the dogs betrayed no disturbance or
uneasiness. They were watched for several days.

In another series of tests, the experimenters waited until the characte-
ristic symptoms of poisoning began to exhibit themselves, and when the
pupil was largely dilated, the respiration embarrassed, the heart beating
rapidly, and the feces and urine were involuntarily discharged, the solu-
tion was rapidly injected. At the end of two or three, and sometimes
five minutes, the various symptoms would disappear, although a general
prostration would remain for some time. As this lessened the dog would
begin to walk and would finally recover. In all cases the solution was
tested by injection into the veins without the antidote, and, in every in-
stance, the dog died.

Lacerda formally expresses his belief that the permanganate of potas-
sium is a positive antidote for serpent poison. His experiments were, many
of them, performed in presence of the Emperor Pedro, and other persons
of distinction in science.

Dr. Badaloni, of Bologna,1 repeated the experiments of Lacerda and
Gouty, but without the same success. This was, I think, largely due to
his different method of proceeding. Lacerda inoculated the venom, pre-
viously obtained, so that there could be no doubt as to the poisoning taking
place. Badaloni compelled the viper, the serpent he employed, to strike
the animal experimented on. Of course, there could be no certainty that

1 Sul valore del permanganate) di potassa quale antidoto del veneno dei serpenti
(ofidi). Kapporto del Giusseppe Badaloni. Bologna, 1882. 8vo.

138

Fletcher, Experiments on Serpent Venom.

[July

venom was injected, except from the symptoms. Further, Lacerda in-
jected the antidote through the same punctures by which the venom had
penetrated, while Badaloni injected it into the neighbouring tissues. In
his first experiment, a rabbit was bitten on the upper lip and on a paw,
and the permanganate solution was injected into the tissues of the shoulder;
in fifteen minutes the rabbit died. In a second case, when the antidote was
injected, two minutes after the evidences of poisoning manifested them-
selves, the rabbit recovered ; but so did a third rabbit, without any treat-
ment. The fourth rabbit was bitten by two vipers, and the permanganate
was injected fifty-five minutes after the first bite and thirty minutes after
the second ; this rabbit recovered.

Badaloni's experiments are inconclusive, but are interesting from the
fact that he records the temperature of the poisoned animal every three or
four minutes. The temperature before the bite was almost uniform at
39.5° centigrade, and it fell in one case to 34.5°, with a steady rise as the
danger diminished.

Mr. Vincent Richards,1 of Calcutta, who had been a member of the
Snake-poison Commission, upon hearing of Lacerda's investigations, in-
stituted a series of experiments upon the effect of the permanganate on
cobra poison. His conclusions were, that the salt, though not an anti-
dote, strictly speaking, was of very considerable value in the treatment of
snake-bites ; that it had the power to neutralize t he venom in the tissues,
but had no effect if the poison had been absorbed into the general circu-
lation. Sloughing, he found to be an almost constant result of the in-
jection of the permanganate. His experiments as to the strength of the
solution required, resulted as follows : He mixed 3^ centigrammes (about
•i- grain) of cobra-venom with the solution and injected it into the cellular
tissue of a fowl.

With a ^ of 1-per-eent. solution, the fowl died in 13 minutes.

" i " " kt " " " "

X u u u « u 18

" 1£ " " " " 59 "

"2 " " the fowl became somewhat

sluggish, but recovered.
"4 " " the fowl was not affected at all.

Permanganate of potash is, according to Le Bon, the most powerful
disinfectant known, but he states that it exerts but little influence upon
microbes.2 This is a view generally held by those who have experi-
mented with antiseptics ; but Dr. G. M. Sternberg, in an article upon
germicides in this Journal for April, places it second in rank as destructive
of germs.

Mr. Richards advises the use of a 5-per-cent. solution, and that, after

1 Indian Med. Gazette. Calcutta, 1S82, xvii. 1; 57; 85.

2 Comptes rendus, 1882, ii. 259.

1883.]

Fletcher, Experiments on Serpent Venom.

139

the injection, the parts should be kneaded and pressed with the fingers, so
as to distribute the antidote.

Lacerda's method was also tried by Theodor Aron, an assistant of Pro-
fessor Binz, of the University of Bonn.1 His experiments were made
with cobra-venom which had been sent from India, in a dried state. He
mentions that a part of the solution which had become absolutely putrid
was scarcely at all diminished in its virulence. Of 13 rabbits inoculated
with the poison, and treated with the permanganate of potassium, 7
died. He had greater success with a solution of chloride of calcium, for
in 22 experiments with that antidote he saved 17 of the rabbits. He
tried the effect of alcohol, of caffeine, atropine, and brucine, but all proved
valueless. Aron's experiments appear 10 have been carefully made. He
inoculated two rabbits with the same quantity of venom in each instance,
and administered the antidote to one only. The other always died.

In the Journal cV Hygiene for September 22, 1881, Dr. de Fourier men-
tions having received a letter from a captain of engineers, dated at Banana
de Itaguaby, in Brazil. Captain Rezende says : —

" While we were measuring the grounds around the imperial farm of San Luiz,
one of our surveyors was bitten above the heel, about two o'clock in the afternoon,
by an enormous serpent, the jararaca pregnicosa,2 which measured a metre and
a half in length. Before leaving Rio 1 had provided myself with a bottle of the
solution of permanganate of potassa, recommended by M. de Lacerda, and im-
mediately made five hypodermic injections with it, two into the wound itself
and three above the instep. The patient also drank a teaspoonful of the solu-
tion. At the time I write, eight o'clock in the evening, the surveyor limps a
little, but has none of those terrible symptoms which always follow the bite of
this serpent."

Professor Vulpian, in a note read to the Academy of Sciences in Paris,
a short time since,3 commenting on Lacerda's experiments, declared the
permanganate of potassium to be dangerous to life when introduced into
the circulation. Half a gramme of the salt which he injected into the jugu-
lar vein of a small dog produced death. A great many experiments have
been made, especially by Sir Joseph Fayrer, to test the action of sup-
posed antidotes when injected into the veins or tissues of animals, without
the accompaniment of the venom, and conclusions have been drawn as to
their poisonous qualities, as in this statement of Vulpian's. It may be
doubted whether these conclusions are warranted. The presence of venom
in the blood or tissues may modify the otherwise toxic action of the anti-
dote. It certainly does in the case of stimulants ; alcohol is tolerated,

1 Experimentelle Studien iiber Schlangengift. Von Theodor Aron. Centralblatt f.
klin. Med., 1882, No. 31, Nov. 18.

2 I suppose this is a printer's blunder for pemiciosa ; or it may be meant for the
Portuguese word preguigosa, sluggish.

3 Comptes rendus, 1882, xciv. 611. Etudes experimentales relatives a Taction que
peut exercer le permanganate de potasse sur les venins, les virus et les maladies.

140

Fletcher, Experiments on Serpent Venom.

[July

without ill effects, in quantity sufficient, at other times, to produce exces-
sive intoxication, if not even coma.

Before leaving the subject of Lacerda's experiments, a curious circum-
stance remains to be told. Dr. Couty, his assistant, sent a communica-
tion to the Academy of Sciences, which was read at the meeting of April
24, 1882, in which he reverses the opinion he had previously expressed,
and declares that the permanganate does not even mitigate the activity of
the bothrops venom when the latter is injected into the veins. He ad-
mits, almost unwillingly, that it decomposes the venom in the tissues. Dr.
Couty gives an account of a few experiments he had made, in all of which
the dogs operated upon died.

Lacerda has not, as yet, made any communication to the Paris Academy
in reply to this statement of his former coadjutor, but he addressed a note to
the Jornaldo Commercio, published at Rio de Janeiro, in which he alludes
delicately to the fact that the friendly relations between himself and Dr.
Couty had been interrupted, and that, consequent upon that condition, came
this surprising recantation of the latter.1 He points out that in Couty 's
latest experiments, 2 c. c. of a saturated solution of venom, representing fif-
teen or sixteen bites of the bothrops, were injected directly into the circula-
tion, and that the remedy could not overtake it when in such deadly quantity.
Further, he asserts that the permanganate is a chemical antidote, and not
a physiological one, that contact, and speedy contact, is therefore neces-
sary. He reasserts the conclusions drawn from his numerous experiment-.
He might have added that injecting the venom into one saphena vein, and
the antidote into the other, unnecessarily increased the danger of absorption,
and that a one per cent, solution of the salt was too feeble as against the
concentrated venom employed. In short, the experiments seem rather to
have been planned to produce a failure, and their negative results cannot
be set against the positive success of Lacerda, and that of Richards and
many others, with the more deadly cobra poison.

The records of scientific research afford many surprising instances of
contemporaneous discovery — discoveries with identical results, made at
nearly the same time by independent observers. About the time that
Lacerda was experimenting with the venom of the bothrops in Brazil,
Dr. Armand Gautier, of Paris, arrived at very similar conclusions as to
the neutralizing power of caustic potassa in relation to cobra or rattlesnake
venom. His communication upon the subject was read at a meeting of
the Academy of Medicine, July 26, 1881. 2 Lacerda's paper was presented
to the Academy of Sciences September 2, but as it was sent from Brazil,
it is clear that the two investigators arrived at similar conclusions about
the same time.

1 O permanganate de potassa contra a mordedura de cobras. Gaz. med. de Bahia.
1882, 2 s. VI., 550-559.

2 Bull. Acad, de med. Par., 1881, 2e ser., X., 779 ; 948.

1883.] Fletcher, Experiments on Serpent Venom.

141

GautierV experiments with serpent venom arose during his researches
into the nature of the ptomaines. A word or two of explanation as to the
nature of these substances may be necessary. Ten years ago, Selmi, of
Bologna, discovered in a cadaver certain alkaloids closely resembling the
well-known vegetable alkaloids, such as aconitine, veratrine, morphine,
and others. These new bodies were the products of putrefaction, and he
called them ptomaines, from Ttt^^a, a carcass. Strange to say, nearly about
the same time, Gautier also discovered these alkaloids to be developed in
putrefied blood. Further investigations have shown that ptomaines are
also found in the living body, and they have been discovered in the urine
of fever patients, in healthy urine, saliva, blood, muscular juice, in the
serum of ovarian cysts, in the amniotic fluid, and in some other animal
fluids.

When it is remembered that these ptomaines are violent poisons, that they
respond to reagents just as the poisonous vegetable alkaloids do, differing
only in the velocity with which the reducing power is exerted, that they are
produced in certain morbid states of the living body, and are generated by
putrefaction in the cadaver, we must admit the enormous importance of
the discovery in its relation to medical jurisprudence. Brouardel speaks
of it as the " sword of Damocles" hanging over the head of the expert in
toxicology.

Time will not admit of more than this mere mention of the subject, but
its relation to serpent-venom remains to be told. Gautier obtained from
healthy saliva sufficient ptomaine to destroy birds. The saliva was pro-
cured direct from the duct of the parotid gland, so that it was uncontami-
nated by the impurities of the mouth. The points of resemblance of ser-
pent-venom to the new alkaloids are as follows : they are not ferments ;
heat long applied leaves them both nearly as deadly as before. Gautier
boiled the serpent-venom, filtered it, and evaporated it to dryness ; still,
when dissolved in water or glycerine, it would destroy life. He exposed it
to a temperature of 125° C. for several hours, without diminishing its
potency. The toxic effect upon animals is the same with both. At first
is observed restlessness, then rapid breathing, coma, paralysis, convulsions,
and death with the heart in systole. After death, the muscles do not con-
tract under the stimulus of the electric current. Professor Corona' says
the loss of muscular contractibility is produced by none of the vegetable
alkaloids excepting muscarine, the active principle of poisonous fungi,
which strongly resembles the ptomaines in its effects. Both serpent
venom and ptomaines respond alike to chemical tests, and have the same
reducing power. A singular peculiarity has been observed in both, of
them, that the gastric juice increases their virulence, while the admixture
of bile diminishes it.

1 Gianetti e Corona. Sugli alcaloidi cadavericio ptomaine del Selmi. Memoria letta
all' Accad. di Sassari, XIX. Adunanza, 1880.

142

Fletcher, Experiments on Serpent Venom.

[July

In the course of his experiments, Gautier found that the injection of a
solution of caustic potassa into the veins or tissue, in combination with
cobra venom, made the poison innocuous. When it is remembered that
the permanganate of potassium is soon decomposed in the blood, and
caustic potassa remains, the identity of the discovery and conclusions with
those of Laeerda is evident and remarkable.

Dr. Corre, of the French Navy, some time since gave an account of the
symptoms produced by certain poisonous fishes in tropical countries, and
they strongly resemble the effects just described, of ptomaines and serpent
poison. M. Remy finds that the genital organs, the ovaries, and the
testicles, are the poisonous parts. A bouilli made from them and injected
under the skin of two dogs produced death, while the other parts of the
fish proved to be inert.1

Before leaving the subject of the ptomaines, I wish to draw attention to
a passage in Dr. Weir Mitchell's account of his experiments with rattle-
snake venom, published in 1868. 2 He said : " The one form of poison
which most resembles venom is that of putrefactive substances,, and I am
inclined to think that from putrefying material may yet be separated a
substance, which, concentrated, will prove active toxically, and will, per-
haps, enable the observer to repeat the facts I have witnessed here."
This prediction was made in 1868, three years before Selmi made known
his discovery of the cadaveric alkaloids.

The ptomaine theory would be incomplete without reference to another
pathological process in which the omnipresent bacteria figure. It is be-
lieved by Gautier, Le Bon, Dr. Ogston, of Edinburgh, and others, that
these micro-organisms, when in large quantities, engender ptomaines.

They argue that when a small inoculation is made into the tissues — for
it must be understood that this form of the germ-theory involves tissue-
poisoning rather than blood-poisoning — the blood acting only as the car-
rier— a rapid increase of micrococci takes place, with local irritation and
subsequent pyaemia. If a larger quantity of the poisonous fluid be injected,
ptomaines are developed in proportionate amount, and a fatal result rapidly
follows.

It cannot be said that the development of ptomaines from micrococci, or
of the -latter from the former, for both views have been maintained, is any-
thing more than a hypothesis — proofs are, as yet, wanting. But, all theory
apart, there is no doubt as to the fact that, while inoculation of serpent-
venom or animal-poison into the blood or tissues, in large quantity, or of
a specially virulent quality, will produce rapid death by paralysis of the
nerve-centres, smaller injections, or of a less virulent material, will pro-

1 Note sur les poisons toxiques du Japou. Comptes rendus Soc. de biologie, 1883,
iv. 263.

2 Experimental Contributions, etc., p. 23.

1883.]

Fletcher, Experiments on Serpent Venom.

143

dnce great local irritation and even gangrene, followed by septicemia and
probably death.

There appears to be some similarity to the latter process in the action
of the sui, or needle-poison, of India.1 The seeds of the Abrus preca-
torius, known as rati or gunchi seeds, are used as an article of food in
times of scarcity, but if the powdered seed, even in small quantity, be
injected into the cellular tissue, it produces inevitably fatal effects. The
chamars, or skinners, as they are called, robbers who steal or destroy
cattle in order to sell the hides, make the powder into a paste, and form
from it the or needle, which is a spike about three-quarters of an
inch in length, resembling a cock's spur. It becomes very hard and
sharp when dry, and, having been inserted into a wooden handle, it is
driven by a forcible blow into the skin of the animal. Some instances
have recently occurred of its fatal use on human beings, and the composi-
tion of the sui poison has been made the subject of official investigation.
At one time it was supposed to be dried serpent venom, but its effects are
different. There is neither paralysis, difficult respiration, convulsions, or
coma, as in acute serpent-poisoning. As the sui liquifies, it produces
intense cellulitis, with inflammation of the lymphatics, and, as it slowly
finds its way into the circulation, great depression of the vital powers
ensues, ending in death. Extreme weakness with local swellings are the
only symptoms. Two dogs, which were experimented upon with it, died,
the one in 49, and the other in 55 hours. It is very probable that when
a competent observer investigates these cases, he will find the tissues and
fluids of the poisoned animal swarming with bacteria.

It is not within the scope of this paper to relate the results obtained
with the various remedies for serpent poison, except in connection with
recent experiments, but a few words must be said as to the value of
ammonia injected into the veins or tissues. The evidence in regard to
this remedy is contradictory and puzzling.

Professor George B. Halford,2 of the University of Melbourne, has
recorded many cases, observed by himself and others, in which the use of
ammonia seemed wonderfully successful. His experiments upon animals
were made with the venom of the tiger-snake (Hoplocephalus curtus). It
has been objected that the bite of Australian serpents is not generally
dangerous. Sir Joseph Fayrer, and other Indian observers, have found
ammonia entirely worthless as an antidote to cobra-poison. Dr. Weir
Mitchell states that it has no value as a chemical antidote, and as a stimu-
lant it is far inferior to alcohol. Professor Halt'ord asserts that serpent
venom produces an enormous increase of the white corpuscles of the blood,
and he attributes this to a germinal matter consisting of nuclei 40V0 inch

1 Indian Med. Gaz., Calcutta, 1882, xvii. 287.

2 The Treatment of Snake-bites in Victoria, Melbourne, 1S70, 8vo.

144

Fletcher, Experiments on Serpent Venom.

[July

in diameter, proceeding from the serpent's glands. Dr. Weir Mitchell's
views are quite adverse to this belief. Prof. Halford further insists that
death from snake-bite is due to deoxidation of the blood, the addition of
the germinal matter from the venom, in some unknown manner, destroy-
ing its power of absorption of oxygen. He asserts that the blood of poi-
soned animals will, after death, speedily absorb oxj'gen to a much larger
extent than unpoisoned blood.

A case has recently been reported in which the new remedy, jaborandi,
was employed with success in a case of snake-bite.1 Profuse salivation
and perspiration was produced, followed by the subsidence of the danger-
ous symptoms.

Dr. AYeir Mitchell has again entered the field of experiment, but this
time his investigations have been made with the assistance of Dr. Edward
Reichert,2 upon the venom of the Gila monster, the Helodcrma suspectum.
This is the only member of the lizard family which is, as yet, known to
be poisonous. Last November a specimen which was in the Smithsonian
Institution, while being examined by Dr. Shufeldt, bit him in the thumb,
inflicting a severe, lacerated wound. The doctor sucked the wound until
bleeding ceased, but the hand began to swell, and such severe pain shot
up the arm and down the corresponding side, that he fell fainting to the
ground. A sleepless night followed, but in a few days the wound healed
entirely. The same lizard was sent to Dr. Mitchell, who obtained its
saliva by forcing it to bite a saucer, into which the secretion dribbled.
The saliva had a faint, aromatic odour, and was distinctly alkaline, in
contrast to serpent-venoms, which are all acid.

About four minims of this saliva, diluted with half a c. c. of water, was
thrown into the breast muscles of a large, strong pigeon. In three min-
utes he began to rock on, his feet, respiration became rapid, short, and
then feeble, convulsions with dilated pupils followed, and before the end
of the seventh minute, the bird was dead. In another experiment, in
which one-sixth of a grain was injected into the carotid artery of a rabbit,
the animal died in nineteen minutes ; and, in another case, death ensued
in a minute and thirty-five seconds. After many other tests of its virulence.
Dr. Mitchell comes to the following conclusions : The poison of Helo-
derma causes no local injury ; it arrests the heart in diastole, the organ
contracting slowly after ; the heart loses its irritability to electric stimuli
at the time it ceases to beat ; the other muscles and nerves respond
readily to irritants ; the spinal cord has its power annihilated abruptly,
and refuses to respond to the most powerful electric currents.

1 Morsure de vip&re ; accidents "-raves ; emploi du jaborandi ; guerison. Gaz. hebd.
de mel et de cbir. , Paris, 1882, 2e ter., xix. 8 55.

2 A partial study of the poison of Heloderma suspectum (Cope), the Gila monster.
By S. Weir Mitchell and Edward T. Reichert. Medical News, Phila. 1SS3, xiii. 209-212.
Also, Reprint.

1883.]

Fletcher, Experiments on Serpent Venom.

145

This interesting and virulent heart-poison contrasts strongly with the
venoms of serpents, since they give rise to local hemorrhage, and cause
death chiefly through failure of the respiration, and not by the heart,
unless given in overwhelming doses. They lower muscle and nerve re-
action, especially those of the respiratory apparatus, but do not, as a rule,
cause extreme and abrupt loss of spinal power.

Dr. Mitchell has made arrangements to have a number of these lizards
sent to him in the spring, when he will prosecute his investigations into
the nature of their venom. The Gila monster grows to the length of
three feet ; the specimen which bit Dr. Shufeldt was fourteen inches long.1

In the Virginia Medical Monthly for February, is an article by Dr.
Isaac Ott, of Easton, Pennsylvania, entitled : " The Physiological Action
of the Venom of the Copperhead Snake — Trigonocephaly contortrix.''
In Dr. Ott's experiments, the snakes were forced to strike the rabbit or
frog, a method, as before stated, lacking in precision. One rabbit died in
two hours ; another, which had been struck by three copperheads, in eight
minutes.

Dr. Ott's principal conclusions are as follows : —

The venom of the copperhead is Aveaker than that of the rattlesnake.

Both reduce the heart's action, and, in cases of large quantities of
venom, death ensues through the heart.

Muscular irritability at time of death is little affected in copperhead
poisoning.

The cardiac force, rhythm, and frequency, and the arterial tension are
lowered by both venoms.

The blood after copperhead poisoning shows no microscopic changes of
its globules, or any difference in its spectrum.

Dr. Ott, like Dr. Mitchell in his experiments with heloderma, made
use of the kymographion, and recorded the variations of pulse and arte-
rial tension. Neither of them seems to have made any record of the
temperature.

The latest, and from the standpoint of physiological chemistry, the most
important addition to our knowledge of the subject is again the work of
Dr. Weir Mitchell. At the recent meeting of the National Academy of
Science, in this city, Dr. Mitchell read a paper describing the results of
some researches made by himself and Dr. Edward T. Reichert,2 with the
fresh venom of the rattlesnake, copperhead, and moccasin. The report
says : " Our work has resulted in the isolation of three distinct proteid
bodies, of which two are soluble in distilled water and one is not. Of the

1 The bite of the Gila monster (Heloderma suspectum, Cope). Am. Naturalist,
Philada., xvi. 907-9.

2 Preliminary Report on tbe Venoms of Serpents. By S. Weir Mitchell and Edward
T. Reichert. (Read before the National Academy of Science. April 18, 18S3.) Med.
News, Philada., 1883, xlii. 469-172. Also, Reprint.

No. CLXXI July 1883. 10

146

Fletcher, Experiments on Serpent Venom.

[July

former two, one is incoagulable at a temperature of 100° C. It may be
obtained by boiling venom, which throws down or destroys all the other
proteids, and then filtering, or by dialysis." This proteid, by a careful
series of tests, they decided to be a peptone, as it answered in"a positive
manner to all the tests for that body, and gave three reactions in addition
not found in any other peptone. It is the only peptone yet known which
constitutes a portion of a secretion, or originates within the living body,
except as a product of the digestion of proteids.

The second proteid, after a like careful series of experiments, has been
determined to belong to the class of globulins. The third proteid has not
been thoroughly separated, but it is an albumen.

These three substances they term venom peptone, venom globulin, and
venom albumen.

The venom peptone is not as poisonous as venom, but produces remark-
able local effects. If injected, in a small quantity, into the breast muscles
of a pigeon, a lump forms, and within forty-eight hours a gangrenous
cavity is formed giving off horrible putrefactive odours. The venom
globulin is of intense virulence. One-twentieth of a grain will kill a large
pigeon in two hours. It is not yet known whether the venom albumen is
poisonous. The power of the venom peptone to produce putrefaction in
the tissues is most surprising. The venom globulin produces rapid extra-
vasation of blood in the tissues.

The crotalus, whose venom was thus analyzed, was the C. adimanteus,
or diamond-back rattlesnake. In his former experiments, Dr. Mitchell
employed the C. durissus, and he has made a singular discovery, namely,
that while the venom of C. durissus was scarcely at all impaired by
boiling, yet the toxicity of C. adimanteus was destroyed by a temperature
of 176° F. The report states, also, that the poisons of the rattlesnake,
the copperhead, and the moccasin can be destroyed by bromine, iodine,
bromohydric acid, sodium hydrate, potassium hydrate, and potassium per-
manganate. This discovery of the separation of venom requires a long
and elaborate series of researches to thoroughly elucidate it.

With this abstract of the extremely important discovery of Drs. Mit-
chell and Reichert terminates this account of recent experiments on ser-
pent venom.

It will be observed that, in some instances, the conclusions of these in-
vestigators seem to be antagonistic, and the remedies, which are all power-
ful in the hands of some, appear to fail in those of others. Still, great
progress has been made in determining the mode of action of venom and
defining its chemistry, and a reasonable hope seems permissible that a
chemical antidote has been discovered which may save many lives.

1883.] Northrup, Emphysema and Abscess of the Lungs. 147

Article XIII.

Extensive Interlobular Emphysema and Abscess of the Lung, after
AVhoopixg-Cough, in a Child of two months. — Unique Case. By
William P. Northrup, M.D., Pathologist to the New York Foundling
Asylum.

Patient is a female, aged two months, New York Foundling Asylum.
She was brought to the asylum and u given up" when one month old.
Her " condition" at that time was recorded as " poor." Three days after
entrance she was put out to wet-nurse in the city. Was returned in eight
days by the nurse because she was " sick and cross."

From this time she was bottle-fed. She was found to be suffering from
whooping-cough and diarrhoea. She gradually fell into that condition
well named " marasmus," and died, aged two months, having been under
observation one month.

Dr. Geo. M. Swift, house physician, states that the notable feature of
this case, to distinguish it from numerous other unfortunate u marasmus
babies," was its severe paroxysms of coughing, accompanied with a well-
marked whoop.

Autopsy, Oct. 27, 1882, twelve hours after death. — Body, emaciated,
abdomen sunken and greenish stained, excoriations about anus and but-
tocks. Brain, not examined. Lungs, bronchial glands somewhat- en-
larged, firm. Left, small area of consolidation along the posterior portion.
Few scattered spots of interstitial emphysema in upper lobe and along the
anterior lip of both upper and lower. These spots appear like rows of air
bubbles, those at the lip assuming larger dimensions, and looking like
elongated sacs. These sacs run upward toward the root of the lung,
between the lobules, for an inch or more. Right, does not retract on
opening the thorax. Red hepatization of nearly the whole of the lower
and middle lobes. The surface of the upper lobe has an opaque, grayish,
parchment-like appearance, irregularly nodulated as though composed of
many variously sized air sacs crowded together.

On section the upper lobe shows a labyrinth of communicating cavities
varying in size from a pea to a filbert. The partitions are in places, ob-
viously, compressed lung tissue ; again fibrous bands, which, becoming
thinner and thinner, either stretch across cavities or are discontinued.
The colour is the same dull, brownish, opaque throughout.

In the middle lobe the departure from normal is less marked. The
lobules are compressed and pneumonic, the interlobular spaces being on
an average equal in size to the compressed lobules.

In the lower portion of the lower lobe it is still less marked. There is
a liberal sprinkling of spherical cavities, half the size of a lentil ; and be-
sides this, a checking off of the lobules, so that a majority of the lobules
are separated from their neighbours on one or more sides by a narrow in-
terlobular fissure. No emphysema of mediastinum nor surrounding tissues.

Heart, normal. Liver, size normal, colour dark, vessels filled with
dark fluid blood. Gall-bladder distended with bile, ducts -pervious.
Spleen, size normal, colour dark. Kidneys, urates in tubules, size and
markings normal. Stomach, post-mortem softening. Intestines, me-
senteric glands enlarged uniformly throughout. Whole abdominal cavity
has a greenish washed-out appearance. Small, contents tenacious,
greenish mucus. Mucous membrane gray and sodden. Peyer's patches

148 North rup, Emphysema and Abscess of the Lungs.

not prominent. Large, con-
tents mucus and flakes of yel-
lowish material. Membrane
gray and sodden. Solitary
follicles pigmented.

Microscopic Appearances.
— To describe the lesions in
order of prominence : —

First. Interlobular emphy-
sema. At the angles of junc-
tion of the partitions above
described, there are to be seen
compressed air vesicles. Even
this likeness to normal lung
is of rare occurrence in the
upper half of the upper lobe.
Removed from the angles the
tissues are more and more
compressed laterally till there
remains simply a band of con-
nective tissue.

Second. Along the lower
border of the upper, and
throughout the middle and
most of the lower lobes there
exist interlobular spaces and
pneumonia together. The
pneumonia is characterized
by an excess of pus. The
bronchi and cells walls are
extensively infiltrated with
it, while in many of the alve-
oli no epithelial elements are
found, and little or no fibrin.

Third. In this portion of
the lung there exists a pecu-
liar condition. Many of the
interlobular spaces are filled
with pus and fibrin in varying
proportions. These lakes of
pus are large enough to be
seen by the unaided eye in an
ordinary section. Besides
these lakes of pus there are
beginning abscesses from
breaking down of luno; tis-
sue.

Fourth. Dilated lymph
spaces beneath the pleura.
In the subpleural tissue there
are seen tortuous, irregularly
dilated canals, which from their course and from the structure of their
walls, seem to be lymph vessels. These can be traced down into the in-
terlobular tissue in several cuts.

Interlobular emphysema ; transverse section of upper
lobe. Enlarged one diameter..

1883.] Grant, An Anomaly of the Human Heart.

149

Fifth. Ordinary recent broncho-pneumonia. This is most abundant
in lower lobe and skirting the lesions mentioned above.

Sixth. Last and least, a few patches of normal lung in the lower lobe.

We have then a case of extensive interlobular emphysema occurring
in, and probably due to, severe whooping-cough. Complicating this is
suppurative interstitial inflammation. The latter process was certainly
advancing at the time of death.

All modern authors speak in a general way of the possibility of inter-
lobular emphysema as result of whooping-cough.

After a long and careful search, the writer is unable to find anywhere
in the literature of emphysema the record of a case similar to the present.
Many are reported of sudden emphysema, showing in the neck, and some,
in which on autopsy, emphysema of the mediastina was found.

Article XIV.

Ax Anomaly of the Human Heart. By H. Horace Grant, A.M., M.D.,
Lecturer on Operative and Elinor Surgery, and late Demonstrator of Anatomy,
Kentucky School of Medicine, Louisville.

I have to report an anomaly in the human anatomy, interesting not
alone from its striking singularity, but as well from its clinical importance.
Almost without exception irregularities in the arterial system affect but
little the sovereignty of the general circulation, the provisions of nature
offering always a compensating arrangement in the notable variations from
the standard. The present instance, however, is an example of grave and
fatal changes resulting from an unsuspected congenital lesion.

In June, 1880, I was invited by Dr. B. A. Garr to assist him in a post
mortem. The subject was a mulatto girl aged 16 years; small stature;
poorly developed ; family history was unknown. Of her illness the doctor
gave the following history : —

She had been under his observation for a year. She presented during
all that time a loud, regurgitant murmur at the tricuspid orifice, increased
precordial dulness, and an irregular pulse ; she had experienced several
attacks of haemoptysis, and had harassing cough ; she had never men-
struated ; her fingers and toes were clubbed to absolute deformity. All
during the doctor's observation of her she had laboured under marked
dyspnoea ; but never presented any pulmonary dulness on percussion, nor
any constant rales. It was made out from the family that most of these
characteristics had existed since birth in a greater or less degree.

Dr. Garr had arrived at a diagnosis of tricuspid insufficiency, and pro-
bable dilatation of the right heart. He referred the haemoptysis to
pulmonary congestion.

LTpon removal of the sternum and pleura, the lungs were disclosed in a
marked condition of pulmonary apoplexy. A great number of hard,
blue-black lumps, representing clotted blood (some of them partially
organized, seemingly), were found in the air-cells and in the interstitia

150

Grant, An Anomaly of the Human Heart.

[July

tissue. These lumps, which, pathologically, are of more than passing
interest, were chiefly upon or near the surface ; in no instance were they
larger than a small cherry, and for the most part smaller, quite irregular,
and invariably beneath, not only the visceral pleura, but within the cellu-
lar tissue of the lung itself; no tubercle was found ; no abscess ; no pus.
As our chief search was directed to the heart, after cutting through the
aorta above the pericardial attachment, and severing the pulmonary ves-
sels at the root of the lungs, we took the heart away with us to examine
it at our leisure. With the assistance of Dr. Geo. J. Cook, late Professor
of Anatomy in the Kentucky School of Medicine, we examined the right
auricle, which was found largely dilated; the right auriculo-ventricular
valve was insufficient, and had permitted of very considerable regurgita-
tion ; the ventricle upon being opened was also found somewhat dilated.
But we were very greatly astonished to find upon further investigation,
that cavity communicating directly with the aorta ; no pulmonary artery
was to be seen attached to the heart ; the left auricle was normal ; the
mitral valve perfect ; the left walls and cavity natural in texture and size,
but presented only one-half the usual attachment of the aorla. In a word,
both ventricles opened writh equal freedom into the aorta. One semilunar
valve attaching to the opening from the right ventricle, one from the left,
and one from the posterior ventricular septum ; the aortic sinuses were as
usual, and the valves perfect ; however, both coronary arteries arose out
of the right ventricle's sinus of Valsalva ; the heart was empty. In our
search for the pulmonary artery we found at the pericardial attachment to
the aorta two arteries given off, each about one-fourth of an inch in
diameter ; they passed right and left backward from the front of the
aorta ; evidently, and beyond question, they supplied the blood to the
lungs. We could not, of course, trace them, since not expecting to find
an anomaly like this we were not careful at the autopsy where we cut the
vessels leading to the lungs. Of course, there was no ductus arteriosus.

In this instance we had a heart acting for sixteen years almost identi-
cally as when the Eustachian valve remains pervious. Here was a mixed
current of blood thrown continually into the general circulation. The
natural dusky hue of the skin obscured the cyanosis which doubtless
existed. The tricuspid insufficiency was, as is usual with such lesions,
probably congenital. It is not difficult to explain most of the symptoms
and signs ; mal-nutrition and carbonic-acid poisoning, on account of the
unarterialized blood, retarded development and disturbed function. So
unusual a clubbed condition of the fingers and toes may be explained by
similar reasoning, such pathological anatomy frequently accompanying
valvular diseases of the heart. The haemoptysis doubtless was from pul-
monary congestion ; but the causation of passire pulmonary congestion, and
of pulmonary apoplexy has always been referred either to stagnation or
obstruction of the venous current from the lungs-. Authorities ascribe it
either to feeble vis a teryo from dilated right ventricle, or else disease ot
the mitral valve, allowing regurgitation and obstructing the flow from
pulmonary veins. Certainly this- congestion was not active, as the hem-
orrhages had been irregularly occurring for several year?, not occasioning
at any time any unusual or pronounced change in the health of the child.
The marked differences presented by the clots declared against the possi-

1883.] Altounian, Statistics of Lithotomy Operations. 151

bility of the hemorrhagic effusion occurring at one time only ; evidently
it was frequently repeated. It is clear, too, that in this 'case no obstruc-
tion to the return of the venous current existed ; the prompt evacuation
of the heart favoured really the pulmonary efferent flow. It is a question
whether this pulmonary apoplexy was really the result of stasis in the
pulmonary circulation, or whether the etiology may not have relation to
the great vis a tergo, of two ventricles forcing the blood into the pulmo-
nary capillaries. If, as is conceded, cardiac hypertrophy may cause
active pulmonary congestion, may not the concentrated power of both
sides of the heart rupture a pulmonary capillary and produce extravasa-
tion in the lung-substance, inducing at times haemoptysis ?

It may be out of place to consider at any length in this article the
pathological relations, my object being only to report the anomaly. Still,
if there be reason to suppose the force of the heart may rupture the capil-
lary walls, a new significance is added to simple hypertrophy of the heart.

It is astonishing that the child should have lived so long, nourished
from birth by blood not more than, if so much as, half oxygenized. The
diagnosis of such a condition during life is, of course, out of the question;
and, indeed, it is doubtful if a parallel case exists in the annals of
medicine. The specimen has been examined by many anatomists, among
others Dr. J. 31. Holloway, Professor of Surgery, and Dr. J. M. Mat-
thews, Professor of Pathology, in the Kentucky School of Medicine, and
is at present in the museum of that institution.

Article XV.

Statistics of 272 Lithotomy Operations. By Xishax Altounian,
M.D., of Turkey in Asia. Translated from the Armenian by his son Mejlkan
Z. Altouxian, M.D. (Jeiferson Medical College).

The 272 lithotomy operations, the statistics of which are given below,
have been performed since 1860. The weight of the calculi varied from
J to 89 drachms. Of the 272 cases, 75 were at the time of the operation,
with the exception of the vesical trouble, healthy. The age of the
patients varied from 1 to 80 years.

Summary of Operations Of the whole number of operations, there

were lateral 64, died 5 ; medio-lateral 167, with 7 deaths ; median 36, 2
deaths; medio-bilateral 5, death 1. As to the composition of the cal-
culi, there were urates 119, with 3 deaths ; phosphatic 71, and 7 deaths ;
unphosphatic 40, no deaths ; oxalate 42, with 5 deaths.

As regards age, there were between 1 and 10 years 47 cases, with 1
death ; between 10 and 20 years, 99 cases, 4 deaths ; 20 and 30, 66 cases
and 2 deaths ; 30 and 40, 38 cases and 2 deaths; 40 and 50, 23 cases and
4 deaths ; 50 and 60 years, 6 cases, no death; 60 and 80, 3 cases, 2 deaths.

152 Altounian, Statistics of Lithotomy Operations. [July

In 4 cases the calculus was adherent ; in 1 case a perineal fistula
remained after the operation ; secondary hemorrhage occurred in 15 cases,
peritonitis in 11, cellulitis in 10, cystitis in 37, and erysipelas in 0.

Methods of Treatment Cases which were in a healthy condition were

never put under preparatory treatment; those suffering from organic dis-
eases or complications, which might militate against recovery, were put
under preparatory treatment. At the time of operation the bladder was
allowed to retain its urine, or water was injected. The bladder should con-
tain from 2 to 12 ounces of fluid according to its capacity and the age of
the patient. If the bladder be not distended, there may be difficulty in
seizing the stone, especially when it is small, but when it contains a con-
siderable quantity of fluid, wounding of the tissues is thereby often pre-
vented during division of the deeper structures; besides, the gush of fluid
forces the stone forward to the neck of the bladder within easy reach.

Chloroform was the anaesthetic used, except in those cases in which it
would obviously have been disadvantageous. The patients were allowed
to remain under the anaesthetic only for a short time, and were never
thoroughly influenced by it.

In cases of arterial hemorrhage, the ligature was always resorted to ; if
there was very free oozing, hot or cold water was applied, hot water being
found more advantageous. No attention was paid to slight oozing. Styp-
tics were not used, it being found that, in the majority of cases, they do
more harm than good, often causing an inflammatory condition.

In removing the stone no attempt was made to enlarge the opening by
force, gentle traction being all that is required ; in some cases, where
the opening was not large enough, the knife was used, the neck of the
bladder being divided laterally.

At present the medio-lateral operation is preferred, especially in chil-
dren, in whom the recto-pubic space is short. A stone as large as a hen's
egg — even larger — is extracted without any difficulty by the medio-lateral
operation ; in fact three stones, each nearly as large as a goose egg, have
been removed by this operation. When the stone is smaller, and there
is a roomy perineum, the median operation is more often used.

The median operation is preferable, however, as giving more room for
the extraction of the stone ; and the cases are less subject to the inflamma-
tory conditions, so often met with in the other operations, often causing
retention of urine, especially in cases of pelvic deformity.

After Treatment — On the day of the operation large doses of morphia
or opium are administered every three or four hours ; smaller doses on
the second and third days. It is then discontinued, unless an inflam-
matory condition of the parts arises, in which case one dose is adminis-
tered at night. The perspiratory secretion is kept up by a mixture of
gum-arabic and cherry laurel water, and some diaphoretic. On the fourth
day a dose of castor oil is given, and afterward, tonics and nutritious diet.

Plethoric patients, in whom febrile symptoms arise, are bled ; anaemic

1883.] J en c k e s , _The Radical Cure of Varicocele.

153

patients are ordered quinine with opium or morphine in small quan-
tities.

Should the wound become inflamed, warm linseed cataplasms are ap-
plied, with lotions of opium and lead-water. When there is supra-pubic
tenderness or pain, warm cataplasms are used along with constitutional
remedies. In cases with high fever, quinine is the remedy, especially in
anremic subjects. Bleeding is preferable in strong plethoric subjects.

It is of great importance that the external wound be kept clean. Dur-
ing the first four days it is washed with warm water. The urine is
closely watched, as too great acidity or alkalinity retards the healing pro-
cess. The great requisites in lithotomy are a. sharp knife, a quick hand,
and an accurate cut. The whole operation was generally performed in
two minutes ; cases of the median operation rarely took five.

Article XVI.

The Radical Cure of Varicocele. By H. Lawrence Jenckes, M.D.,
of Glen Haven, Wisconsin.

The object of this paper is to present in a concise form the operative
treatment for the cure of varicose conditions of the spermatic veins, by
means of a clasp, known as " Williams's Varix Clasp." The idea of con-
tinuous instrumental pressure is not new. It is mentioned in Pancoasfs
Surgery, published some thirty years ago. In the second edition of
Curling on Diseases of the Testis (page 366) is a cut representing an in-
strument by which pressure may be continuously applied. Several cases
are there recorded in which the time required for cure varied from seven
to fifteen months. In the Chicago Medical Journal and Examiner for
May, 1879, an article on this subject appears, by T. W. Williams, M.D.,
describing an instrument by which continuous local pressure may be
applied. In that article (page 471) he states that in about 200 cases the
operation was successful in 98 per cent., and that none died. This, cer-
tainly is a result surpassing any other for the treatment of this disease.

In mild cases, commonly met with, all the treatment necessary is
measures which will well support the testicles — the suspensory bandage.
In cases of a severe nature, where operative procedure is resorted to, the
object in all cases is the same — that of occlusion of the lumen of veiqs.
The radical treatment consists in the obliteration of these veins by the
ligature, the knife, the cautery, or by compression between the blades of a
clamp. Division and excision, as Stimson in his Manual of Operative
Surgery says, "are unsafe, even when the veins are compressed above
and below by harelip pins and twisted sutures." Sir Benjamin Brodie,
Sir Everard Home, and Delpech, recommended and used the ligatures.
Delpech having operated for a double varicocle, a year afterwards was

154 Jenckes, The Radical Cure of Varicocele. [July

assassinated by the patient. Upon the death of the assassin his testicles
were found atrophied. Atrophy and phlebitis are not the only objections
to the ligature. It is excruciatingly painful, and, as Dr. Gross says,
" pain is a great evil."

In the second edition of Curling on Diseases of the Testis (page 359)
I find in a note : " I have been informed that several patients, whose
spermatic veins were tied by Roux of Paris for the cure of varicocle, died
from the operation." Now, any method which the surgeon can devise,
by which the dangers of the operation are lessened — by which the pain is so
slight as in some cases to require but a single anodyne, by which the time
that the patient is obliged to keep his room does not exceed ten clays —
seems greatly preferable to the operations recommended in the text-books.

The objections to subcutaneous ligation are the difficulties experienced
in tightening the loop, and the time required for it to cut its way through.
Ricord's method, as simplified and improved by Dr. Gross, is considered
safe ; but the operation is painful, and phlebitis occasionally results. The
radical cure, as etfected by the varix clasp, is the occlusion of the veins by
continuous instrumental pressure. In applying the instrument, separate the
spermatic artery and vas deferens from the lumen of veins, and with a
tenotomy knife puncture the anterior of the scrotum an inch above the tes-
ticle ; in this puncture insert the pin at the end of the blade. As the in-
strument is held in position, an assistant by turning a thumb-screw forces
the blades firmly upon the veins. The pin at the end of the blade prevents
the veins from slipping from the grasp of the instrument, the blades of
which can be compressed to within one-sixteenth of an inch of each other.
The pain produced by the pressure is of a dull, aching character, and for
the first hour after the application of the instrument is most severe. At
the end of that time the blades should again be so tightened as to thor-
oughly occlude the veins. An anodyne should be now administered, and
if required may be given every evening; although, in a recent application
of the instrument upon a large varicocele, one opiate was all that was re-
quired. The instrument as effectually occludes the veins as though they
were encircled by a ligature, while the suppuration caused by the latter is
avoided. The pressure should be continued four or five days, and at the
expiration of that time, should much oedema of the scrotum follow the
removal of the instrument, a flaxseed poultice will hasten its absorption.
During treatment the recumbent position should be kept by the patient.
As Dr. Williams says : " Owing to the rapidity of the cure and freedom
from internal suppuration, the dangers and inconveniences of the ligature
are avoided."

From these observations and the experience I have had with the clasp,
I consider this superior to any other operative procedure for the cure of
the majority of varicoceles occurring in hospital or private practice. Its
simplicity, its freedom from danger and pain, and its success, render this
operation preferable to any other for the radical cure of varicocele.

1883.]

155

REVIEWS.

Art. XVII. — The Medical and Surgical History of the War of the Re-
bellion. Part III., Vol. I J. Surgical History. Prepared under the
direction of Joseph K. Barnes, Surgeon-General United States Army.
By George A. Otis, Surgeon U. S. A., and D. L. Huntington,
Surgeon U. S. A. 4to. pp. xii., 986, xxix. Government Printing
Office, Washington, 1883.

The completion of this third surgical volume will be a matter of con-
gratulation to all who are interested in military surgery. It has been
eagerly looked for by the profession ever since the issuing of the first cir-
culars from the Surgeon-General's office gave warning of what might be
expected from the material placed within its reach. How well that
material has been utilized the predecessors of this volume have attested*
Planned upon the same lines, carried on with the same command of mate-
rial, and of the same sources of supply, although directed by another hand,
this volume is in no whit behind those which have gone before. The death
of Dr. Otis, so widely regretted, required that another should assume the
direction, and to Dr. Huntington has been granted the honour of com-
pleting what Dr. Otis had planned.

Dr. Huntington is both generous and modest in relation to his own
connection with this volume, and it is pleasant to be able to add that he
has well done the work committed to his care.

Some portions of this volume seem very familiar from the fact that cir-
culars Nos. 2 and 7 have in part gone over the same ground, but the
subjects treated of in those publications have been carefully reviewed, ad-
ditional cases have been added, and the successful results traced through
a longer series of years.

The work consists of six chapters, beginning with X. and ending with
XV. We shall attempt at least a partial analysis of each of these chap-
ters for the benefit of those of our readers who may not find the volumes
accessible.

Based upon 89,528 cases, Chapter X. treats of Wounds of the Lower
Extremities. Of this large number, 59,376 were flesh wounds, and
30,152 were cases in which the bones were involved. In only 674 of the
flesh wounds were they incised or punctured. While the continued recep-
tion at the Surgeon-General's office, even at this late day, of reports of
cases, makes the actual number an increasing one, it is pointed out that
the total aggregates upon which the calculations are based, 253,142
wounds of all kinds, and 89,528 located in the lower extremity,* is suffi-
ciently large to establish ratios which are not likely to be disturbed by
any increase in the number of cases. It would certainly seem as if the
most inveterate statistician might well be satisfied with such figures, and
we very much doubt whether any larger collection of gunshot wounds will

156

Reviews.

disturb the conclusion arrived at in this work, that the ratio borne by
wounds of the lower extremities to the whole number is 35.3. The left
lower extremity was found to suffer somewhat more frequently than the
right.

The magnitude of the materials produced by the War of the Rebellion
is shown by the table on page 2, by which it is seen that the total number
of wounds reported by individual but reliable authorities as occurring in
the Crimean, Italian, Danish, and Franco-German contests, aggregate
much less than one-half the number recorded in the Surgeon-General's
office in Washington. Of course it is not claimed that this table repre-
sents the whole number of wounds received in these wars, but it has been
constructed in order to obtain a sufficiently large number of cases, with
which to compare the ratio established by our own returns.

Attention is called to the fact that with the progress of the war the
proportion of wounds of the lower extremities lessened. This is accounted
for by the increased resort to temporary entrenchments, of which expe-
rience had proved the value, and which more or less perfectly protected
the lower part of the person.

The rarity of bayonet wounds, which was noticed by almost every sur-
geon who had experience in the matter, is further shown by the fact that
the lower extremities were wounded by them but one hundred and seventy-
six times.

Shot wounds involving only the soft parts are considered in two classes,
those in which large nerves and those in which arterial trunks were in-
jured. But fifty-nine cases are referred to the first category and one
hundred and fifty-six to the latter. Many injuries of nerves doubtless
escaped report as such, but the absence of remediable wounds of vessels is
accounted for by the now established rule, established by experience in
the field, that they are of extreme rarity. The conclusions of Dr. Otis
on this point, while opposed to expectations which may be quite naturally
entertained, are abundantly supported, not only by experience, but by the
observations of Heine, Guthrie, and the historian of the Crimean cam-
paign. The mortality in these cases was very large, and Dr. Otis is of
the opinion that there was a failure on the part of some surgeons to ap-
preciate the importance of tying both ends of any vessel that has been
injured by a shot.

While several interesting instances of the lodgment of missiles in the
soft tissues are narrated, none of them equal the somewhat marvellous
accounts given by some writers of the size and weight of foreign bodies
which became imbedded in the thigh and leg. While Dr. Otis does not
directly question the accuracy of these accounts, he evidently inclines to
look upon them as apocryphal when said to exist without fractures. In-
deed, when Hennen tells at second hand, of the bearers of a dying man
complaining that the w eight w7as on one side of the litter, and of a thirty-
two pound shot being afterwards cut out of the hip, we hardly wonder at
the incredulity of the compiler of this volume.

Dr. Otis next proceeds to the consideration of peri-articular wounds,
and differing from M. Legouest, prefers to include in this class those cases
in which the capsular ligament has been opened, but in which the osseous
tissues are uninjured. Such a classification has some practical advantages,
and is supported by other good authorities, as Beck and Fischer. To
make a classification dependent upon an accuracy of diagnosis, always
difficult, and, as in the case of the hip-joint, well nigh unattainable, seems

1883.] Medical and Surgical History of the War of the Kebellion. 157

very unwise, and we, therefore, think the plan of Dr. Otis much the best.
Indeed, so great is the difficulty in connection with this joint, that Dr.
Otis speaks of forty-nine cases appearing on the registers in which the
reporters believed the coxo-femoral articulation to have been opened with-
out direct injury of the bones. Of thirty-five cases where the lesion of
the joint was supposed to be primary, twenty-one recovered and fourteen
died. In fourteen cases the joint is reported as opened in consequence of
secondary traumatic coxitis, seven of which died and seven recovered.

Peri-articular shot wounds of the knee-joint without fracture occurred
three hundred and fifty-one times, the joint having been primarily opened
in two hundred and fifty-five, and secondarily involved in ninety-six cases.
Of three hundred and thirteen cases treated on the expectant plan, two
hundred and forty-four recovered, and sixty-nine died. Of the thirty-
eight cases in which amputation was resorted to, twenty-nine, or 76.3 per
cent. died.

The evidence in regard to the precise nature of the thirty-seven cases
reported as peri-articular shot wounds of the ankle-joint is said to be un-
satisfactory. In fifteen of the cases no operation was done, and one death
resulted ; in twenty-two amputation of the leg was resorted to, and twelve
fatal results ensued.

The complications of flesh wounds of the lower extremities are then
briefly considered. One hundred and ninety-four cases of ligation of large
arteries are recorded. In six instances during the war the common iliac
was ligated, but in only one did the injury leading to the operation belong
to the class now under consideration ; the result was fatal. In four cases
the external iliac was first tied, and in seven a ligature was secondarily
placed upon it after one had been fruitlessly placed upon the femoral.
Professor John Ashhurst, Jr., has commented upon the fact, that with the
increased number of cases the mortality attending ligation of the large
vessels is seen to be larger than was formerly believed to be the case.
The compiler of this volume, however, thinks the remark is less applicable
to ligations of the external iliac. He refers to the fact that in the ex-
tended list prepared by Rabe, in 1875, the death-rate has been advanced
but 3 per cent.

One hundred and twenty-seven cases of ligature of the femoral occur-
ring in the war are tabulated. Sixty-two of these operations were in
cases in which the vessel was primarily injured, and sixty-five were in-
stances of consecutive involvement of the artery. The serious character
of the proceeding is shown by the large mortality which followed its
adoption. Ninety-one died, or 71.7 per cent. Tfre profunda alone was
twice ligated successfully, and four times unsuccessfully.

For shot flesh wounds amputation was resorted to two hundred and
one times, of which one hundred and thirty-one were in the thigh, six at
the knee, sixty-three through the leg, and one of the toes. The mor-
tality in thigh-amputations was 71.7 per cent. As is well known, the
mortality was less grave in the secondary operations. Of the six disar-
ticulations at the knee but one recovered. In the sixty-three amputa-
tions through the leg the mortality was 52.3 per cent. Summaries of
these cases are tabulated, which, as in the case of the other tables of this
great work, will prove of much value to future students.

Section II. of this chapter is occupied with a consideration of Avounds
and injury of the hip-joint. It occupies one hundred and eight pages,
and is dealt with in a manner commensurate to the gravity and import-

158

Reviews .

[July

anee of the subject. Inasmuch as circulars No. 7 and 2 of the Surgeon-
General's office dealt with this matter in considerable detail, we shall
pass over the subject, not because we undervalue its importance, or do
not appreciate the admirable manner in which it is discussed in this
volume, but on account of the vast amount of material which is still be-
fore us, and which we almost despair of being able to compress within the
necessarily restricted limits of this review. We will only say that three
hundred and eighty-six cases of shot fractures of the hip-joint are re-
corded in this section, of which three hundred and four were treated by
conservation, with two hundred and forty-nine deaths and fifty-five
recoveries ; fifty-five cases were submitted to excision, with fifty-three
deaths and two recoveries ; while in twenty-seven cases amputation was
resorted to, with twenty-five deaths and two recoveries. Sadly unsatis-
factory as such a record is, the observations in recent European wars have
shown no better results, and it can only be said that progress in the treat-
ment of this injury is proved by the experience that it is not always fatal,
as was once thought to be the case. There is one practical point yet re-
maining to be settled in the cases of those reported as recoveries after
gunshot wound of the hip-joint, namely, the actual amount of injury.
There are thought to be fifty sucli cases still living in this country, and
twenty -five are reported by Langenbeck as the result of the Franco-Prus-
sian war. So far, out of those who have since died, no post-mortem ex-
aminations are known to have been made. It is to be hoped that as
deaths among the remainder occur, exact and minute investigations may
be made on this point, thus helping to solve a very important and much
mooted question.

Section III. is occupied with a consideration of injuries of the shaft of
the femur, all of which were produced by shot. The number of such
cases recorded amounts to 6738, of which 3020 were treated expec-
tantly. Although but 2901 were submitted to amputation on account of
injury to the femur, the total number of amputations of the thigh re-
corded in this volume is G238 ; the increase being accounted for by
the very large number of cases in which the operation was resorted to for
injuries sustained by the knee-joint and leg.

One hundred and sixty-two instances of shot contusion of the shaft
of the femur are recorded, of which nine were treated by amputation, and
one hundred and fifty-three were treated expectantly, with a mortality of
22.8 per cent. Pyaemia and secondary hemorrhage were the grave com-
plications, and were the principal factors in producing the fatal issue.

Six thousand five hundred and seventy-six shot fractures of the shaft
of the femur are next considered, of which three thousand four hundred
and sixty-seven were treated by conservation, and three thousand one
hundred and nine by operation. Without considering the portion of the
femur involved, the treatment by conservation resulted in the recovery of
sixteen hundred and eighty-nine, while sixteen hundred and eighty-four,
or 49.9 per cent. died. In the six thousand two hundred and twenty-
nine cases of thigh amputations, twenty-eight hundred and thirty-nine
recovered, and three thousand three hundred and ten died ; a mortality of
53.8 per cent. This mortality exceeds the mortality attending conserva-
tion 3.9 per cent., but is 15.6 per cent, less than the ratio of deaths fol-
lowing excision of the shaft of the femur, which reached 69.4 per cent.
This is a very gratifying evidence of the advance made by modern sur-
gery in a class of cases which a few years back were considered hopeless.

1883.] Medical and Surgical History of the War of the Rebellion. 159

Great care has been exercised by the Surgeon -General's office to follow
up these recoveries, and numerous well-executed lithographs present the
more or less satisfactory results which have been obtained. The success
attending conservative treatment, as also in those cases where operation
was resorted to, was of course materially modified by the position of the
injury, whether iu the upper, middle, or lower third of the femur.

Excisions in the continuity of the shaft of the femur were done one
hundred and seventy-five times, but the results were discouraging, and
the procedure is not regarded favourably by surgeons either in this coun-
try or abroad. Of the cases recorded in this volume, fifty-one recovered,
one hundred and sixteen died, making the mortality 69.4 per cent., and
in eight the result could not be ascertained.

Proceeding with the consideration of this subject, amputations of the
thigh are next treated with great thoroughness, and in much detail. In-
asmuch as the operation was resorted to in very many cases of knee-joint
and leg injuries, the numbers which the historian has had to deal with
are augmented to 6229 cases which have not been before considered.
The cases are divided according to location in the upper, middle, and
lower third of the bone, and into primary, intermediate, and secondary.

Without reference to locality, three thousand nine hundred and forty-
nine amputations were done within forty-eight hours, and. are therefore
classed as primary, and of this number nineteen hundred and fifty-eight
were successful, of forty-eight the result could not be ascertained, and
nineteen hundred and forty-three died, a mortality of 49.8 per cent. We
shall not attempt to follow the subject into the details as regards location,
which are pursued in this section, and the results summarized in numerous
tables, further than to say that in the upper third of the thigh amputations
had a mortality of 53.8 percent.; in the middle third of 44.5 per cent.; in the
lower third 53.6. while in those where the seat of the operation is unre-
corded the mortality was 80.7 per cent. It will be seen that when prim-
ary, intermediate, and secondary operations are thus grouped together, the
mortality is increased, amounting indeed to 53.8 per cent.

Thirteen hundred and twenty intermediate amputations of the thigh
were done, of which four hundred and seventy-nine were successful, and
eight hundred and forty-one were fatal, giving the formidable mortality of
63.7 per cent.

There were four hundred and forty-two cases in which amputation of
the thigh was resorted to after the thirtieth day from the receipt of the
injury, and are therefore styled secondary. Of these, two hundred and
thirty-nine recovered, and two hundred and three died, a fatality of 45.9.

Five hundred and eighteen cases of amputation through the thigh are
recorded in which the intervals between the injury and the operation are
not noted. In all but thirty-two cases the results have been ascertained, and
it has been found that one hundred and sixty-three were successful and
three hundred and twenty-three died, making the mortality rate 66.4 per
cent.

In the total number of 6229 thigh amputations the femur had been
fractured in 46.6 per cent.; the knee-joint in 38.5 per cent.; the bones of
the leg in 13.8 per cent.; and the ankle-joint or foot in 1.1 per cent.

By Table XLVII. a comparison is possible between the results of thigh
amputations in other wars and those done in our own civil conflict. With
great labour a collection has been made of nine thousand and seventeen cases
from reliable authorities, and the death-rate is seen to be 83.2 per cent.

160

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[July

There is a very judicious and impartial summing up of the results ob-
tained, and the claims for the expediency of conservative treatment are
shown to have grown and strengthened of late years. Indeed it would
seem as if the attempt to save the limb should be made, when the shot
fracture is unaccompanied with injury of the large vessels or nerves, or
other serious complication, as affording an equal prospect of preserving
life, and sometimes resulting in a useful limb. Especially is this the case
when a good, immovable extension apparatus can be applied at once, and
be kept on continuously.

The form of amputation adopted varied with the views of the different
operators, and a chromo-lithograph pictures six very good stumps obtained
by different methods. The flap operation seemed to be most favoured,
and it, or some modification of it, was most frequently resorted to. We
do not, however, see anything in this section to positively decide as to
the respective merits of the two methods. The opinion of Dr. Batwell,
contained in the First Surgical Volume, is quoted, in which he condemns
the modification by which skin flaps are first made, and the muscles then
divided by circular incision. There is, however, an apparently inten-
tional witholding of anything like an authoritative expression of opinion
on the part of the historian himself. The same fact is observable as
regards any pronounced judgment upon the various forms of dressing
employed when conservative measures were adopted. Nothing can exceed
the care and pains-taking accuracy which distinguish this most important
section.

Twelve punctured, thirty-nine incised, and three thousand three
hundred and ninety-eight shot wounds of the knee-joint are considered
in Section IV. The punctured wounds all recovered, and there was
evidently some doubt on the mind of Dr. Otis, whether some of them at
least were not merely periarticular wounds. Seven of them were received
from that rather useless weapon, the bayonet. The thirty-nine incised
wounds were all produced by axes or hatchets. Thirty-three were
treated expectantly, and four of the number died. In six cases, amputa-
tion of the thigh became necessary, and all but one died.

Of the shot injuries of the knee-joint, forty-three were recorded as shot
contusions, thirty-three of which were treated without operative inter-
ference, eleven dying, or 33.3 per cent, and twenty-two recovering.
Accurate as this book generally is, there seems to be an error in collect-
ing these cases. For while on page 364 there occurs the statement given
above, on the next page we are told that ten cases terminated fatally.
Ten cases suffered amputation of the thigh, and eight of the number died.

Of the thirty-three hundred and fifty-five cases of shot fracture of the
bones of the knee-joint, eight hundred and sixty-eight were treated upon
the expectant plan throughout. The results in nine instances have not
been ascertained. Three hundred and thirty-eight were successful, and
five hundred and twenty-one fatal, being a mortality of 60.6 per cent.

We cannot pass by the remarkable case which belongs to this category,
which is narrated in part in Dr. J. Mason Warren's Surgical Observa-
tions. At the battle of Antietam, Lieutenant Baker, 35th Mass., stooping
to staunch the flow of blood from a wounded comrade, was himself struck
by a ball which passed diagonally through the left elbow-joint, and enter-
ing the outer aspect of the left knee-joint, lodged in the outer condyle of
the femur. Under judicious expectant treatment he got perfectly well,
recovered all the motions of the elbow-joint and all those of the knee

1883.] Medical and Surgical History of the TTar of the Rebellion. 161

except that of extreme flexion, and engaged in active business until his
death, from pneumonia in 1878. After death the bullet wAs found firmly
impacted in the outer condyle of the femur. The articular cartilages were
perfectly smooth, there was no channel leading to the ball, nor the slight-
est evidence of caries existing. The boues entering into both the elbow
and knee-joints, with the ball, impacted in the outer condyle for fifteen
years, are figured in this volume.

Several other most interesting and remarkable cases will be found
narrated under this group.

Excision of the knee-joint for shot injury was done fifty-seven times,
and of these forty-four died, and the result in three is unknown, making
the mortality 81.4 per cent. The brilliant anticipations of the value of
this operation in military surgery, at one time entertained, were not
realized. Of one hundred and eighty-nine examples of amputation through
the knee-joint for shot injury clone to it, the result in two cases could not
be ascertained; eighty-one recovered, and one hundred and six died,
making the mortality 56.6 per cent., exceeding the fatality attendant
upon amputation of the thigh in its continuity either of the lower, mid-
dle, or upper third.

The conclusion arrived at by most surgeons, who had much experience
in the war of the Rebellion, was, that when the knee-joint received a
gunshot wound, amputation .in the lower third of the thigh offered the
best prospect for saving life, and the experience of later wars is in coin-
cidence with this view. It should be mentioned that while the mortality
from amputations through the knee-joint was large, the stumps obtained
by the proceeding were satisfactory, and thought to be better adapted for
wearing an artificial leg than was the case when the operation was done
higher up.

The fifth section of this chapter, containing one hundred and fifty pages,
treats of wounds and operations in the leg. Our space will not permit of
our doing more than merely to glance at this interesting and important
section. The number of cases in which the leg was injured was enor-
mous, nine thousand one hundred and seventy-one instances of shot-
Avounds involving the bones being entered on the records. One hundred
and eighty-three of these are entered as contusions of bone, but the
others were all fractures, of which three thousand nine hundred and thirty-
eight were treated without operative interference, giving a mortality rate
of 13.8 per cent. This is a decided improvement upon the showing made
by a series of cases collected from the reports of military surgeons in
other wars, which had a mortality of no less than 18.5 per cent. It would
appear, however, that while the mortality was small the reports upon the
nature of the results made by the pension examiners, from time to time,
are by no means such as are to be desired — deformity and diseased tissues
being very often the burden of these reports. False joint is only known
to have resulted seven times.

The statistics of the war of the Rebellion, and the experience in recent
European contests, have pretty much settled the question as regards exci-
sions in the continuity of long bones. Early in the war there was much
expected from that measure, and some cases were seen by the writer of
this review, but the records of the Surgeon-General's office demonstrate
pretty clearly that it should be banished from military surgery, and in
the opinion of the writer, from civil surgery as well ; deformed and use-
less limbs are the best results which can be hoped for from what one sur-
geon most properly terms an " unphilosophical operation."
JSo. CLXXI July 1883. 11

162

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[July

The amputations of the leg numbered, according to the records, five
thousand four hundred and fifty-two ; and though the mortality was 32.9
per cent., it compares favourably with that prevailing in other wars.
Attention is called to the curious fact that amputations in either the
upper or lower thirds of the arm, thigh, and leg, were attended with a
higher death-rate than when the middle third was selected. Very little
attention was paid by American surgeons to the point of selection, the
operation being done at the farthest possible point from the trunk, yet
experience seemed to show that amputations in the middle third did
better, led to secondary amputations less often, and were more conserva-
tive of life, than those done in the lower third.

Section VI. is occupied with a consideration of wounds and operations
at the ankle-joint. The experience of the American civil war would
seem to confirm the opinion that conservatism was out of place where
the injury was of the bones entering into the ankle and involving the
joint. Of one thousand seven hundred and eleven such cases, in five
hundred and eighteen conservation was practised ; in thirty-three, exci-
sion was resorted to, and in eleven hundred and sixty-two, amputation
through the joint, in the leg, or in the thigh, was had recourse to. The
mortality attending conservative treatment was 19.5 per cent., and the
ultimate results in many cases less favourable than was at first anticipated.
The substitution of excision effected no gain over the results of amputation,
so far as saving life was concerned, the mortality in the former being
29.0 per cent., and in the latter 25.1 per cent.

The respective methods of amputating at the ankle-joint, known as
those of Syme and Pirogoff, were both practised, the former the most
largely. Eighty-three after Syme gave a mortality of 25.6 per cent.,
while forty-nine after Pirogoff had a death-rate of 28.5 per cent. These
numbers are too small to establish what may be regarded as the normal
rate of death in these operations, and we are inclined to think that the
statistics of the war leave the question as to the comparative merits of
the two proceedings unsettled. There seems to be no doubt that Syme's
method leaves a stump better adapted for the application of an artificial
limb ; but while having a lower death-rate, it would seem to be more
apt to be followed by reamputation than the method of Pirogoff. The
difficulty of getting firm union between the surfaces of the tibia and
calcis in the method of Pirogoff is balanced by the proneness of the flaps
to slough in that of Syme. The statement made in circular No. 6, upon
the authority of the surgeon-in-chief of the Russian navy, Baron von
Haurowitz, that Pirogoff had abandoned his method of operating, is said
in this volume to be unfounded.

In Section VII., on wounds and operations in the foot, twenty-seven
shot contusions, and five thousand eight hundred and thirty-two shot frac-
tures are examined as regards their treatment and results. Here also
excisions were not attended with very happy results, and amputations
either upon the formal lines of Chopart, Lisfranc, and Hey, or by simply re-
moving the injured parts, were attended with fair success.

In concluding an examination of this chapter, which extends through
six hundred and thirty-nine pages, we would express our high estimate of
the exhaustive manner in which the work has been done. Not only are
the results of the American war examined, but an elaborate attempt has
been made to place before the reader those obtained by military experience
elsewhere. By these tables it is possible to institute comparisons, and to

1883.] Medical and Surgical History of the War of the Rebellion. 163

observe the later experience gained, bringing the subjects up to the most
recent dates. In addition, the previous experience had with especial
methods of treatment is summarized at considerable length in the foot-
notes, so that the student has placed before him a very complete history
of the subject under discussion. The thoroughness with which the ulti-
mate results have been followed out, in very many cases by the diligent
use of the facilities possessed by the Pension office, adds immensely to the
value of this volume. By the use of such means, it is seen that the end
of many cases is quite different from that which was expected at the time
they were under the surgeon's hands. In the light of these records, many
cases which were discharged with the hope that they would soon cease to
suffer inconvenience, are seen to have gone through the tedious and dis-
tressing processes, which any one familiar with the surgery of bone has
learned to dread.

Chapter XI. is a short one, consisting of two sections. It is based upon
171,565 miscellaneous injuries which were sustained by the troops engaged
in the great conflict, estimated at 2,335,942 men. They consisted of
burns, scalds, contusions, sprains, dislocations, frostbites, simple and com-
pound fractures, punctured, incised and lacerated wounds. Inasmuch as
they did not differ from the injuries occurring in civil practice, there is
no attempt made to treat them in the exhaustive manner bestowed upon
wounds received from instruments of war. We notice one case of stroke
by lightning, on p. 655, in which persistent efforts by artificial respiration
and the exhibition of stimulants, were successful in restoring life, although
the patient was not seen by the surgeon until ten minutes after the occur-
rence, and the man was to all appearances dead. The deaths from light-
ning are by no means rare, but it is unusual for a medical man to be
called early enough to accomplish anything. On page 656, there is re-
corded a case of scorpion bite successfully treated by Bibron's antidote and
stimulants. The case occurred in Virginia, and has especial interest in
view of Mitchell and Reichert's recent experiments, with bromine as an
antidote to serpent venom.

Section II. has to do with the numerous operations done for disease and
miscellaneous injuries. The list is quite large and varied. We notice
one amputation of the thigh for a carcinomatous tumour in which the ex-
emption from return had continued until the time of issuing this volume,
or eighteen years. The microscopical examination was by an undoubted
authority, Dr. J. M. Da Costa. Such successes are worthy of especial
notice, as they encourage attempts to relieve cases that are hopeless with-
out operation.

Chapter XII. is occupied with a general discussion of wounds and com-
plications. As it is general rather than statistical, it is very interesting,
and will probably be more generally read than some others on which much
greater labour has been expended. Out of 246,712 cases of wounds by
weapons of war but 922, or 0.37 per cent, were produced by sabres or
bayonets, and of these by far the greater number occurred as the result of
quarrels, or in the discharge of guard duty. This very small percentage
is much less than in recent European wars. The introduction of long-
range repeating fire-arms would almost seem to have rendered these time-
honoured weapons obsolete. Thus we learn that in the by no means in-
frequent hand-to-hand skirmishes which took place between bodies of
cavalry, the carbine and pistol were most generally relied upon, and that
very often the sabres were not even sharpened, nor the men instructed in

164

Reviews.

[July

their proper use. When cavalry were opposed to infantry they were
almost invariably at once dismounted and fought on foot.

The proportion of shot wounds of different regions was not found to
correspond to the superficial area of the principal divisions of the body as
calculated by Longmore. These areas have been found to be as follows,
according to careful measurements of the Pythian Apollo and the Farnese
Hercules: Head, face, and neck, 8.51 per cent.; trunk, 28.91; upper
extremities, 21.14; lower extremities, 41.41. Of the wounds treated in
the American war, 10.77 per cent,, were of the head, face, and neck, 18.37
of the trunk, 35.71 of the upper extremities, and 35.15 of the lower ex-
tremities. Either the uneven nature of the ground on which battles are
fought, or the greater or less use of intrenchments must account for the
difference found between the theory, and the observed facts. Of course
in a large proportion of those struck in the trunk, death occurred on the
field, and as the location of such wounds were not considered, it materially
affects the proportion.

The character of the different projectiles used is discussed at consider-
able length, and the variations in the nature of gunshot wounds produced
by missiles of rapid velocity are dwelt upon. The appearances of the
various missiles are figured and their construction explained with some
detail. In the midst of these details, having to do with the sickening
ingenuity of man to produce destructive agents, it is refreshing to come
across a paragraph stating that the use of " Greek fire" was occasionally
resorted to, but that representations of its barbarity led to a discontinuance
of it. Reference is also made to the attempt made to discourage the use of
explosive bullets, which culminated in the meeting of representatives of
European nations at St. Petersburgh in 1868, where it was decided to
discontinue their use in any wars that might occur between the contract-
ing parties. One hundred and thirty cases of wounds supposed to have
been caused by such missiles are recorded, and in some of them there
could be no doubt that they had been used. Gardiner's explosive bullets
were at one time issued by the Ordinance office in small amount, but more
than one-third fell into the hands of the Confederates, and no more seem
to have been issued. By a foot note, we learn that in the contest with
Chief Joseph's band of Nez Perches Indians, wounds from explosive bul-
lets were observed, and the mystery was explained when it was found that
just before the outbreak the Indians had captured the rifles and ammuni-
tion of a hunting Englishman. There is no doubt that many wounds pro-
duced by missiles of high velocity present such an amount of destruction
of tissues as leads to the supposition that explosive bullets have been
used.

The injuries caused by large projectiles are referred to and the old
theory of " windage" disposed of once more. The instances of cerebral
concussion from the bursting of shells near by were not very rare, and the
paralysis, deafness, and other nervous symptoms which ensued, were in
some instances permanent. A very curious case is given in this connec-
tion, in which aneurism of the abdominal aorta was caused by the -firing of
an 84-pound gun immediately underneath the, patient. The prevalence of
deafness among artillerists is well known to be often dependent upon lace-
ration of the membrana tympani. The distortion which leaden bullets
undergo when they come in contact with bones and other hard substances is
shown in a large lithographic plate, looking very familiar to those of us whose
experience reaches back to the sad days of the rebellion. Two coloured

1883.] Medical and Surgical History of the War of the Rebellion. 165

lithographic plates are also given affording very good illustrations of some
of the appearances of wounds of entrance and exit.

We are tempted to enliven the dull course of this review by copying the
foot-note on page 713, illustrating the contusion which may be produced
by a bullet : —

" A soldier found an iron breast-plate, probably thrown aside by some Con-
federate, on the field at Kingston, N. C, and put it on. He was struck by a
Minie-ball on the breast-plate over the region of the third rib and severely con-
tused. He expectorated a full pint of blood and suffered from dyspnoea ; the next
day he was able to walk about. Since the reception of the wound a round excava-
tion about the size of a Belgian Minie-bullet has sloughed out at the point where
he was hit, laying bare the rib. The same breast-plate was worn by another
soldier at Whitehall, with less fortunate result. A Minie-ball struck it near its
lower border and passed through it, carrying fragments of it into his abdomen,
causing death."

The effects following wounds of nerves are considered at some length,
the classical and almost unique work of Drs. Mitchell, Morehouse, and
Keen, being very freely quoted from. There are hardly any more unsatis-
factory cases than those in which large nerve trunks are cut by shot.
Unless there is speedy improvement, the prognosis must be that the
symptoms will be very generally more or less permanent, and it would
seem as if the character and severity of the symptoms pretty accurately
foreshadowed the after history of the case. How sad and hopeless such a
history may prove, is well shown in the case of Captain Johnson, who, when
21 years old, had the rectum, and the vessels and nerves which supply
the lower extremity, cut by a ball which entered one sacro-sciatic notch
and passed out at the other. The wound was received at Jackson, Miss.,
in May, 1863, and, being taken prisoner, he remained such for seventeen
months. He lived until 1878, and, through all those weary years, was
obliged to lie upon his face. At the time of his injury, he was in perfect
health, six feet and one inch in height, and weighed 200 pounds. Before
his death his weight was estimated not to exceed 70 pounds. How much
of misery and anguish is represented by the difference! Well did men
in those days sing of " when this cruel war is over !"

The effect of missiles upon bloodvessels are considered at a length pro-
portioned to the importance of the subject. Apart from the wounds of
large trunks which were speedily fatal, the number of cases of divided
arteries was small. A few observations indicate that very many of the
" killed" died from hemorrhage, yet but one hundred and eighteen cases
are recorded where bleeding occurred from vessels completely divided,
and which were within the possibilities of surgical assistance. Of these,
thirty-four were attended with primary, and eighty-four with secondary,
hemorrhage. Eighty of the cases proved fatal. Three thousand two
hundred and forty-five cases of arterial hemorrhage are recorded, and two
thousand two hundred and thirty-five of them where the bleeding vessel
was definitely ascertained are tabulated, and subjected to careful analysis.
One thousand one hundred and fifty-five ligations were done for shot
wounds. The common carotid was the seat of ligation eighty-two times,
of which nineteen recovered. The external carotid was tied seven times,
with four recoveries. The subclavian artery was subjected to ligature in
fifty-one cases, with ten recoveries ; the axillary forty-nine times, with
seven recoveries ; the circumflex eighteen times, with eleven recoveries ;
the brachial one hundred and seventy times, with one hundred and nine-
teen recoveries. The common iliac was ligated unsuccessfully five times,

166

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[July

and the internal iliac three times with the same result. Six ligations
of the gluteal were followed by two recoveries ; twenty-six of the ex-
ternal iliac by three recoveries. The femoral was tied three hundred
and seventy-four times, and in ninety-four successfully. Of twenty-
two ligations of the profunda, five died, and of thirty-six cases, where
the popliteal was tied, eight were fatal. The anterior tibial was tied
forty-seven times, the posterior tibial forty-eight times, and the peroneal
four times, with twenty-six, twenty-nine, and three deaths respectively.
Traumatic aneurism occurred in seventy-four cases, with a mortality of
68.9 per cent. Of course the mortality which we have transferred to
these pages is but a slight guide to an accurate estimate of the dangers
attending arterial injuries. The existing conditions most seriously com-
plicating the results.

Bleeding occurred at various times, but the number of cases very sensi-
bly increased from the fourth to the tenth and eleventh days. No cases
where acupressure was resorted to are reported. Torsion was employed
in a few cases, and the actual cautery once. Two cases of transfusion are
reported, one of which was successful. Styptics were very commonly used,
and, while there is no doubt that they were often resorted to when correct
surgery called for other measures, Dr. Huntington thinks that the evi-
dence as to their usefulness is not altogether unfavourable.

Several authorities speak of the rarity with which it is necessary to do
a surgical operation to restrain hemorrhage on the battle-field. But a
number of such operations were done during the war of the rebellion, and
seem to have been quite successful.

One hundred and six cases of hemorrhage from veins are tabulated, in
five of which ligation was resorted to. This table shows that wounds of
veins were attended with quite as great mortality as were wounds of
arteries. From the serious effects attending the few wounds of veins
observed, experienced military surgeons suspect that many of the deaths
upon the field occur from venous hemorrhage.

Five hundred and five cases of tetanus were observed, being 0.20 per
cent, of the injuries by weapons of war. The preponderance of cases in
connection with wounds of the lower extremities, which has been re-
marked upon by Beck, was very marked, two hundred and ninety-two
belonging to that class. This is thought by the authors of this volume to
be owing to the masses of muscles and soft tissues which interfere with
the thorough removal "of foreign bodies and other obnoxious influences."
The mortality does not seem to have been high, only reaching 89.3 per
cent. The disease made its appearance with the greatest frequency on
the eighth day. The treatment was empirical, and nothing was added to
our knowledge in this respect by the experience of the war. The coloured
troops furnished 2.7 per cent, of the total shot injuries, and 3.1 per cent,
of the cases of tetanus.

There existed so much confusion in the minds of many surgeons upon
the subject that it has been found impossible to determine with accuracy
the cases of traumatic gangrene, hospital gangrene, dry gangrene, etc.
All cases of gangrene following shot wounds have therefore been tabu-
lated together, aggregating two thousand six hundred and forty-two, while
the various forms are illustrated by examples, or special reports. Espe-
cial reports by Drs. Keen, Goldsmith, Brinton, Thomson, and others are
valuable contributions to the history of hospital gangrene. Several epi-
demics appeared from time to time, and much discussion took place as to

1883.] Medical and Surgical History of the War of the Rebellion. 1G7

the best escharotic. Fuming nitric acid, acid nitrate of mercury, and
bromine were all used, and found effective. There was much disposition
to laud the latter of these agents especially, and it answered very well ;
but it has the disadvantage of being very unmanageable, and the irritating
character of its fumes makes it difficult to properly inspect its application.
With the progress of the war surgeons ceased to dread the disease, as it
was found that prompt and thorough local treatment, with isolation of the
cases in hospital tents, put an end to its extension.

Traumatic erysipelas was of comparatively infrequent occurrence, only
one thousand and ninety-seven cases being recorded in this volume. Quite
frequently acute suppuration and diffuse inflammation, or diffuse osteo-
myelitis were confounded with erysipelas, but such cases have very properly
been separated. The observation that erysipelas occurs most frequently
in connection with wounds of the head and upper extremity was corrobo-
rated by the experience of the American war. The mortality rate of the
whole number of cases was 41.0 per cent. In Louisville bromine was
used, of course, elsewhere iodine and creasote applications were relied
upon, with general sanitary measures. The disease prevailed under the
unfavourable conditions which inevitably attend over-crowded wards. Its
attendance upon excisions was very marked. No connection between
erysipelas and different seasons of the year was observed. It prevailed
most when the largest number of wounded were undergoing treatment.

Septicaemia, ichorrhaemia, and the other terms used to describe the
various degrees or phases of blood-poisoning are all classed together as
pyaemia, so justly dreaded during the war, and, indeed, the great scourge
of civil surgical practice. They are grouped together for the sake of con-
venience, and not with the idea of antagonizing the theories of writers
and observers. Septicaemia may show itself before any pus has formed,
and therefore cannot be pyaemia, but difference of origin does not alter
the grave facts that the vital fluids are depraved, and the result is death.
Not that no cases of recovery occur, but they are very few, and can only
be regarded as exceptional. Out of two thousand eight hundred and
eighteen cases of pyaemia following shot wounds all but seventy-one ended
fatally, a mortality rate of 97.4 per cent. It made no matter whether the
wounds were grave or slight, nor where they were situated, the patients
died. This complication of wounds made its appearance at various times
after the receipt of the injury. From an examination of the series in
which the time of the onset of pyaemia was noted, it is seen to have been
most frequently upon the sixteenth day, but the wave began at the second
day, and did not end until after the three hundredth. In many cases the
disease did not appear until after excision or amputation, and there seems
to be no doubt in the mind of the author of this volume that the pyaemic
infection was induced or influenced by the operative interference. Of
course, this is only the record of a fact, and there is no inference that it
should have any weight in determining the question of operative inter-
ference. Surgical resources are limited, and when an operation is neces-
sary there should be no hesitation in undertaking it, because pyaemia may
supervene. As will be seen by the mortality, treatment was of little
avail. Quinine would lower the temperature for a time, but the effect
was temporary. In a few cases amputation by removing the infecting
focus seems to have saved life, but when once fairly established the
tendency downward was irremediable.

Many cases of multiple wounds were observed. One man, having been

168

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[July

exposed to a cross-fire at Spottsylvania, presented no less than twenty-
eight wounds of entrance and exit. He lived, nevertheless, eighteen
days.

With the progress of the war the tendency to depend upon conserva-
tive treatment increased. Especially was this the case in shot wounds of
the upper extremity. There was also a marked growth in the disposition
to attempt to save in shot injuries of the lower end of the femur, and Dr.
Huntington thinks that the many favourable results leave the wisdom of
the course beyond doubt. Still surgeons in the field and those in general
hospitals entertain wide differences of opinion, which can only be recon-
ciled in view of the results garnered in this volume. As we have before
observed conservative treatment was followed by the least satisfactory
results in the case of the ankle.

It seems to be pretty well settled by the experience of the war that
excisions are more fatal to life than amputations; and especially is this
seen to be the case in view of the fact that over four-fit ths of those done
in military practice were of the upper extremity. Yet the historian is
of the opinion that the favourable results obtained in civil practice should
encourage military surgeons to persist in this direction in suitable cases,
and under favourable circumstances. To decide which are suitable cases
this book affords the best criterion, in the detailed histories it contains.
Even a cursory examination of this most exhaustive volume shows that
excisions in the long bones and in the knee and ankle-joints were little less
than disastrous, and the ultimate results often deplorable. The experience
of the war went to further establish the rule that the requirements of a
given case are best decided at the primary examination, and amputations
done at once saved very many lives ; those that were done during the
inflammatory stage, and classed as intermediate, were notoriously unsuc-
cessful. As before remarked the best method of amputation is not decided
by the experience of the war, and circular and flap will continue to have
their advocates, and to yield good results. One hundred and seventy-two
double amputations were performed, with a mortality varying with the
gravity of the operations.

Chapter XIII. deals with the subject of anaesthetics. It is computed
that they were resorted to no less than eighty thousand times during the
war of the rebellion. It has been impracticable to examine critically this
enormous number of cases, but from an analysis of eight thousand nine
hundred of them it has been found that chloroform was used in 7G.2 per
cent., ether in 14.7 per cent., and a mixture of ether and chloroform in
9.1 per cent. These percentages differ from those given in Circular
No. 6, which was based principally upon the returns of general hospitals ;
but when the returns of work done on the field came to be examined, it
was found, as was to be anticipated, that the smaller bulk of chloroform
caused it to be preferred in so many cases as to raise the percentage from
60 to 76.2.

While the statistics of the war furnish no' data to determine the effect
of anaesthetics in saving life, its historian is convinced that the favourable
percentages of mortality after major operations were largely obtained by
their general use. A number of deaths from the exhibition of anjesthetics
were reported. These amounted, in the case of chloroform, to 5.-4 per
thousand ; of ether, to 3.0 per thousand; and of ether and chloroform, to
2.4 per thousand. In view of the stress of circumstances under which
chloroform was administered, the number of deaths was quite moderate.

1883.] Medical and Surgical History of the War of the Rebellion. 169

Of the four deaths attributed to ether, three of the cases were in an ex-
tremely exhausted condition, and the deaths can with great fairness be
attributed to their physical condition rather than to the anaesthetic, while
in the fourth, the result was evidently attributable to the injudicious ad-
ministration of an over dose. Since the war, the attempt has been made
to obtain reliable data from the experience of army surgeons, and an
analysis of the results thus far obtained is given, but the number is too
limited to be of much value as yet, though an examination of the tables
furnished would seem to add weight to the claim that ether is the safest
anaesthetic. Chloroform, from its smaller bulk and more rapid action,
will always be in favour in military field hospitals, or wherever the pres-
sure of cases requiring operation is out of proportion to the surgical staff ;
but ether is without doubt entitled to the front rank among anaesthetic
agents as yet known to the profession, under all other circumstances.

Chapter XIV. has for its title The Medical Staff and Materia Chirur-
gica, and in its pages will be found an interesting account of the organi-
zation of the medical department, which, during the rebellion, cared for
6,454,834 cases of wounds and disease, and expended in so doing
$47,351,982.24 during the years 1861-1866.

The zeal, courage, and ability of the medical officers is borne witness
to by this work. Many died in the pursuit of their duty, and the strain
made upon them, both physical and mental, was not exceeded in any
other branch of the service. Indeed, the moments of idleness were few to
the faithful medical officer. The long periods of inaction which preceded
and followed many of the great battles were times of ceaseless effort on
the part of the medical staff. Thirty-two were killed in action ; eighty-
three were wounded, while the total number of deaths in rebel prisons,
from accidents and other causes incidental to their position, aggregated three
hundred and thirty-six. Chapter XV. and last, treats of the transporta-
tion of the wounded. Considerable space is given to the various sugges-
tions made as to suitable forms of cacolets and horse litters. Much time
and money were expended in this direction, with little or no good result.
The weight of the apparatus, the difficulty of obtaining and keeping pro-
perly trained animals, and the rough and wooded condition of many parts
of the country in which military operations were carried on, prevented
their adoption. Stretchers and ambulances were the means chiefly relied
upon for the removal of the wounded from the field, and after the organiza-
tion of the ambulance corps they were found amply sufficient. It was some
time before this corps was established owing to the opposition the plan
met with from the commanders, who objected to anything which increased
the size of the army trains. The immense advantages of a regularly
drilled body of men, whose sole duty was to care for the sick and wounded,
were, however, too great to be thus overcome, and, after several partial
authorizations, an Act of Congress was passed in March, 1864, by which
the organization of a proper ambulance corps was ordered and placed
under the control of the Surgeon-General. By this Act the results of
the severe fighting during the last year of the war were much mitigated,
and the wounded of the Wilderness — Spottsylvania Court House, Cold
Harbor, Petersburg, and the campaign in Georgia and the Carolinas —
were promptly and systematically removed from the field, and transferred
to proper base hospitals with a minimum of suffering and delay. This
was a triumph for the Medical Department, and was unattended by any

170

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[July

of the stampedes or panics which it was feared by General Halleck would
attend the presence of the noncombatants of the ambulance corps.

Considerable space is given to the various forms of ambulance wagons
proposed and tried through the war. Of these the Wheeling pattern,
and later on that devised by Brigadier-General Rucker, were by far the
best. The first was very light, could accommodate two recumbent pa-
tients, and was very largely used during the early part of the war. Later
the Rucker ambulance was very generally adopted. It could accommo-
date four persons lying down, and nothing superior to it is as yet known.

Next follows a very interesting though brief account of the methods
adopted for transporting the sick and wounded over long distances by
means of trains and boats. Early in the war box cars were largely used,
bunks being arranged in parallel rows, and windows cut for the admission
of light and air. Many thousands were thus conveyed to base hospitals
with comparative comfort ; but with the progress of the war, and the
more perfect organization in every branch of the service, very great im-
provements were introduced, until the fully equipped " hospital train"
was evolved. These trains were used both in the East and West, but
attained a higher development in the latter region on account of the dis-
tance at which military operations were carried on from the base line.

When Sherman was before Atlanta, previous to his march to the sea-
board, these trains ran daily, and the distance to the base line was four
hundred and seventy-two miles. The engine, stacks were painted a bright
red, and three red lanterns were hun^r beneath the headlight at night.

7 COD

To the honour of our temporarily estranged brethren of the South, be it
said, that no instance is known in which either regular or partisan Con-
federate troops interfered with trains so designated. On one occasion,
such a train was stopped by Morgan's scouts and switched otf on a siding.
After inquiring whether the hospital train had sufficient stores for the
sick and wounded, they tore up the main track, and then pillaged and
destroyed five supply trains which had arrived at the spot. A complete
hospital train carried everything needed by the sick, being to all intent
an ambulatory hospital. It consisted of ten cars, and accommodated
about two hundred patients. It contained one box car for stores, one
kitchen car, one passenger car with seats, for the more slightly wounded,
five cars with beds, an office car for the surgeon, and a caboose for the
conductor and other train hands, such as is ordinarily attached to freight
trains. Detailed plans of these cars are given.

On western rivers and the Atlantic coast transports were largely used
for the removal of the wounded, and an interesting account of the arrange-
ment of the boats used for the purpose completes the work, and brings us
to the end of our task.

A few general remarks upon this monument to the efficiency with
wiiich the affairs of the Medical Department were administered will not
be out of place. A distinguishing feature is the thoroughness with which
cases have been pursued to their conclusion. Xo pains have been spared
to attain this end, and with the aid furnished by the records of the Pen-
sion office, the ultimate issues of very many cases are laid before the
reader, in a way hardly equalled by any other work. To accomplish this
has required an amount of clerical labour not at the disposal of any pri-
vate writer ; but those who have had the work in hand have certainly
made good use of the advantages placed at their command by the govern-
ment.

1883.] Medical and Surgical History of the War of the Rebellion. 171

The care which has been taken to present the views of other writers,
and to compare the results of other military experiences, is a very com-
mendable feature in the work. In foot-notes upon particular subjects
will be found a summary of those experiences, which help to give many
of the subjects discussed the completeness of monographs, so that the stu-
dent who turns to any particular part will find it treated in an almost
exhaustive manner. Of course absolute completeness of returns is not
claimed for this volume. Nor was completeness possible. In the dark
days of the Rebellion the writer of this review served in a hospital near
the front, where, from the incompetence of the surgeon in charge, and
the exigencies of the situation, very imperfect records were kept, but the
totals recorded in this history are sufficiently large not to be affected by
the omission of a few operations, and the averages obtained may safely
be trusted in judging of the merits of any surgical procedure treated of
in its pages.

No less than one hundred and eighty tables have been prepared for this
one volume, many of which are extended and elaborate, exhibiting enor-
mous labour and care in their preparation. Five hundred and ten wood-
cuts are introduced into the text, while forty-four lithographs and chromo-
lithographs illustrate subjects and cases of especial interest. Some of
these last are of more than average excellence, and all are creditable
specimens of the modern lithographic art. There is also included a list
of operators and authors who furnished accounts of the cases included in
this volume, a table of contents, and a subject-matter index of the entire
surgical part.

As we have turned over these pages, we have come across, the names of
many friends, of many who in the years that have supervened have risen
to eminence in their profession, and this feature gives to these ponderous
tomes a personal interest which does not always pertain to surgical works.
This feature will of course disappear with time, for already many names
familiar to us then represent but memories to us now ; but the value of
these volumes will be permanent. Dr. Otis, who planned and executed
so much of this great work, did not live to see its completion ; and since
this book was laid on our table, Dr. Barnes, under whose direction
it was prepared, has also died. We mourn for the departed; but those of
us who witnessed the pangs and woes, and bore our small part in the suf-
fering and sorrow of the war of the Rebellion, will be glad to let their
memories of those events pass into the comparatively dim realm of history.

On a bright morning in the spring of 1863, in Tennessee, the writer of
this notice first heard of the proposed Medical and Surgical History of the
War, from gentlemen connected with the Surgeon-General's office. One
of them has lived to occupy, with distinction, a professor's chair in the
Jefferson Medical College, the other, soon afterwards, met his death in
one of the numberless conflicts carried on upon the waters of the Missis-
sippi. After twenty years it remains for us to express our high sense of
the value of this part of that history, and of the ability, judgment, and
thoroughness with which it has been carried to completion. S. A.

172

Reviews.

[July

Art. XVIII. — The Pathology and Treatment o f Diseases of the Ovaries
(being the Hastings Essay for 1873). By Law-ox Tait, F.E.C.S.,
Edinburgh and England, Surgeon to the Birmingham Hospital for
Women, Honorary Fellow of the American Gynaecological Society, etc.
Fourth edition, re-written and greatly enlarged. New York : illiam
Wood & Co., 1883.

It is possible that the author of this work is still a stranger to many in
this country. He holds no position as teacher in any of the great schools
of medicine of Great Britain, and his name is therefore not prominently
before the profession. The original essay, of which this book is the out-
growth, had no circulation here, while his small but excellent Manual of
Diseases of Women was re-published in such a way that the number of its
readers could but be limited. But he will need no introduction to those
who have seen the results of his operations during a few years past, as
published in the journals,1 and they will eagerly welcome a book from his
pen. To others, who have not been so fortunate, it will suffice to say that
Mr. Tait has attained a position never before reached by one of his age
outside the metropolis. Farther than this, they will learn his characteristics
from this work. The individuality of the author is marked on every page.
He is one of those who hold opinions and is not backward in stating them.
Nor does he wear second-hand mental garments, for upon some very im-
portant points he is at issue with the great majority of the surgical world.
His creed is based on his experience, and that has been both wide and varied.
He is independent, original, and enterprising ; a bold and skilful operator ;
candid and honest in confessing his mistakes. When we add that in this
book he presents and sustains novel doctrines in physiology and pathology,
describes and recommends new operations, and extends the bounds of
abdominal surgery, that he records a success which has never heretofore
been attained, we think it will justify, and even demands, a somewhat
extended and careful examination.

The opening chapter is upon the Anatomy and Physiology of the
Ovaries, subjects to which in former days the author has devoted careful
and close study. While he refers frequently to the researches and teach-
ings of De Sinety and of the lamented Balfour, he relies largely upon his
own observations, especially upon points yet unsettled, or as to which
there is difference of opinion. Some of these are very important and of
practical interest, to many of them can be given but a passing mention.
Thus, he dissents from the statement of Waldeyer, which has been current
of late years, that the posterior surface of the ovary is not invested with a
peritoneal layer. From the course of development there should be such a
layer, and having made a special study of the subject the author states that
he has demonstrated it. He finds in the anatomical arrangement and
structure of the ovarian veins an explanation of the greater frequency of
ovaritis and dislocation of the ovary on the left side ; and, extending the
doctrine a little, we suppose also of the very general existence of pain in
the left iliac region in "uterine" cases. Credit is given to Dr. Brinton,
of Philadelphia, in his researches as to the greater frequency of varicocele

1 An account of one hundred and ten consecutive cases of abdominal section, per-
formed since November 1, 18S0. — Jfcdical Times and Gazette, Nov. 1881.

An account of two hundred and eight consecutive cases of abdominal section, per-
formed between Nov. 1, 1831, and Dec. 31, 1882.— British Med. Journal, Feb. 17, 1883.

1883.] Pathology and Treatment of Diseases of the Ovaries. 173

in the male on the left side, for the discovery of the fact that the spermatic
vein on that side has no valve. The author is not a believer in the an-
alogy between menstruation and the "rut" of animals. But now comes
Dr. Wiltshire1 with an elaborate study of the subject in the light thrown
upon it by the doctrine of evolution — a doctrine in which Mr. Tait is a
believer, and thinks he proves the "identity" of character of the two
phenomena. So authorities still differ ! Mr. Tait is not a believer in the
dependence of menstruation upon ovulation. So far as the argument
against the generally received doctrine is based on the continuance of the
function after double ovariotomy, it is worthless in view of one fact, fully
recognized on a preceding page, which is, that supernumerary ovaries are
not infrequently found. Thus, Beigel gives eight cases in which there
were one or more extra ovaries, out of three hundred and fifty examina-
tions— a proportion large enough, certainly, to meet the exceptional in-
stances in which this incongruity of menstruation after ovariotomy appears.
He fully adopts the teaching of Ritchie, that the formation of Graafian
follicles goes on from an early period of life, and that this doctrine explains
the occurrence of ovarian tumours in young children, and the development
of dermoid cysts. Accordingly we find the doctrine that " the whole pro-
cess of ovulation goes on before puberty," and "the structure of the ovary
does not seem changed in the least by the accession of puberty, save in its
vascular arrangements." The continuance of ovulation alter the meno-
pause follows as a matter of course, and the author says r —

" I have seen, in the ovaries of very old women, structures which I could not
have decided as being in any way different from those seen in the ovaries of
women in the prime of life."

The co?yus lutenm is, to the author, no evidence of menstruation or of
pregnancy, and, as he states what he has seen, it is but just to present it : —

" I certainly have seen, in one ovary of the ninth year, an appearance which I
could not have told from an adult corpus luteum, of about fifteen days after rup-
ture of the ovisac."

"It by no mean/ follows, however, that an ovisac thus delayed in disappear-
ance has been the seat of an ovum which has been fertilized, for I have seen
three such corpora lutea in the ovary of a woman who had been confined, seven
months before my operation, of one child — her only one."

He denies, therefore, all medico-legal value to this structure, and
••would not give an opinion, from any number of corpora lutea, as to
whether they indicated past pregnancy or not."

What, then, is the origin of menstruation — this " curious and objec-
tionable phenomenon," as the author terms it — " for which no one has ever
yet suggested a useful object ?" And what is the seat of the great change
which marks the transition of puberty, if it be not in the ovaries ? The
answer to both queries is — the Fallopian tubes. The power of these tubes
to attach themselves to the ovaries, changes in their structure — vascular,
muscular, and epithelial — are at once the evidence of puberty and the
cause of menstruation. Doctrines so novel and important require, in
justice to the author, full statement : —

" It is perfectly certain that no one has yet recorded one instance in which the
tube has been seen fastened to the ovary before or after the menstrual period
of life as it is during that period. Yet ovulation goes on before puberty and after
the climacteric freely. The change in size and vascularity of the tubes at puberty,

1 British Medical Journal, 1883.

174

Reviews.

[July

and their diminution at the climacteric, and the beginning and cessation of their
movements, form, the most curious of all, the most remarkable features of those
functional changes, and are quite enough to show either that the tubes are more
markedly under the same periodic influence as that which produced the men-
strual flow, or that they themselves are the cause. Finally, I have, during the
last few years, had the opportunity of seeing the ovaries of a number of women,
whose abdominal cavities 1 have had to open for various conditions not connected
with diseased ovaries, and I have always found that during menstruation the tube
is fastened on the ovary, whether there be a ripe follicle at the point of adhesion
or not ; that both tubes were generally fastened to the respective ovaries, though
in one ovary there may have been no appearance of a ripe ovisac ; that I have very
frequently seen an ovisac on the point of bursting, or just burst, when the patient
was midway between two menstrual periods, this being a very frequent experi-
ence, as I always selected, when I could, a time midway between the periods for
my operation, and in these cases I never found the tube fastened on the ovary.
Finally, I have removed, in two cases, ovaries with the tubes fastened on them,
during menstruation, in none of which were there any ovisacs approaching ripe-
ness."

This is strong testimony as to the independence of ovulation and men-
struation. In the failure of the fimbriated extremity of the tube to grasp
the ovary just over a ripened vesicle, a matter entirely accidental, the
author finds an explanation of the tact that conception does not take place
far more frequently, and as it should were ovulation and menstruation
always coincident.

The relation of the doctrine of the tubes being the real source of the
periodic flow from the uterus will be seen further on. Meantime, if it be
true, the removal of them should always certainly cause cessation of men-
struation. Such is the argument as to the ovaries : menstruation con-
tinues, in some cases, for months after removal of these glands, therefore
they cannot be its cause. Now, forty pages or so farther on, we find an
account of twenty-two cases in which the author removed the tubes, and
this statement : —

" Menstruation has, in most cases, been arrested immediately, but in a few it
has lingered for a month or two."

This is just what happens after double ovariotomy. The statement will
hold good for the one case as well as the other. The deduction is obvious.

The second chapter of the work is devoted to several pathological con-
ditions of the ovaries and oviducts, and considers some subjects of great
practical interest. The ovaries are extremely liable to be arrested in their
normal development, and this condition gives rise to delayed puberty, to
dysmenorrhea, and to premature menopause. The zymotic diseases,
especially scarlet fever, are believed by the author to be the cause of this
arrest, and his remarks upon this class of cases are well worthy of attention.
He uses, among other therapeutic measures, Simpson's intra-uterine gal-
vanic stem pessary. Considerable space is devoted to dislocation of the
ovaries, the greater part of it to inguinal hernia of the ovary, but his
remarks upon the displacement into the retro-uterine pouch deserve more
notice here from their practical value. He quotes Goodell freely as to the
serious consequences and treatment of this affection. TThile he does not
doubt that, in many cases, the dislocation causes no suffering at all. in
others it renders life a burden and a prolonged misery. He points out
that in far the greater number of cases the dislocation follows a miscar-
riage or labour, and bears a close relation to sub-involution of the uterus.
Both ovary and uterus are congested, far heavier than normal, retroversion

1883.] Pathology and Treatment of Diseases of the Ovaries. 175

of the one and dislocation of the other follow, and chronic inflammation is
the result. Intractable menorrhagia, aggravated monthly' by menstrua-
tion, is a leading symptom until confirmed invalidism is established. This
introduces the first notice of Battey's operation. In diagnosticating be-
tween a retroflected or retroverted fundus and an enlarged and tender
ovary, the author carefully directs that the finger should be relied upon,
and that the sound should not be used, as it is sure to do serious injury if
adhesions exist. He strongly condemns a resort to this instrument in
these cases, and indeed, elsewhere in the book, shows that it is far from a
favourite with him : —

" If I may here venture to sum up my experience of this instrument, extend-
ing now more than twenty years, 1 would say that it has done an infinite amount
of mischief, and that probably we should have lost nothing if it had never been
invented, and that the more experience grows in practice the less will this instru-
ment be used."

Necessarily, as the result of the author's physiology, inflammation of
the tubes plays an important part in pathology, and has consequences of
the utmost importance. Destruction of the epithelium is one of them,
entailing sterility, and causing tubal pregnancy, for the author refuses to
accept the doctrine that conception takes place, as a general rule, before
the ovum reaches the uterus ; hence, the epithelium being lacking, the
ovum is delayed on its passage, and its development in the tube favoured.
But occlusion of both ends of the tubes is by far the most serious lesion,
and from it results hasmato-, pyo-, and hydrosalpinx, according to the
quality of the fluid which distends them, but the conditions which deter-
mines the nature of the fluid are not known. It is for these conditions that
the author has practised the operation of " removal of the uterine appen-
dages," an operation which has excited a great deal of opposition, has been
the subject of a great deal of animadversion, and which is still under dis-
cussion. In a number of cases, where removal was impossible, he has
opened the cyst, introduced a drainage-tube, and stitched the walls of the
cyst to the edges of the wound in the abdomen, and thus effected a cure.
But, if possible, entire ablation of both ovaries and tubes is performed.
The details of several cases are given in full.

''All my patients, twenty-two in number, have recovered, and of those in
which a sufficient time has elapsed since the operation I can say confidently that
they are all completely cured."

The history of the cases which require this severe mutilation always
shows a severe pelvic inflammation, which may have been puerperal or
the result of suppression of menstruation or of gonorrhoea. The symptoms
are pain — severe pain — especially after intercourse and during the
monthly periods, and, generally, profuse menstruation or metrorrhagia.
The physical signs are enlarged and painful ovaries, generally fixed in
position.

"Distinct fluctuation can often be felt, and their peculiar sausage-like shape
has frequently enabled me to diagnose correctly the condition previous to the
operation."

',' No treatment whatever relieves these cases, save removal of the uterine ap-
pendages."

" Most of my cases had been in the hands of some of our most eminent special-
ists before they came to me, and an infinite variety of treatments, both by drug
and operation, had been used fruitlessly. They had all been treated by pessaries,
and many of them had had their cervical canals dilated and cut."

176

Reviews.

[July

In opening the subject of extra-uterine pregnancy, the author pays a
tribute to the value of the lamented Parry's treatise, and quotes Thomas
as agreeing with himself as to the few varieties which exist, as compared
with the minute distinctions and multiple classification of former writers.
He admits the tubo-ovarian, the tubal, and the interstitial, although in
another page, he says : " I maintain that every case of extra-uterine preg-
nancy is tubal in its origin, and that it may become intra-peritoneal or
extra-peritoneal, just as the tube happens to burst."

It is to be regretted that one so successful in abdominal surgery as the
author has had no cases of ruptured cyst rescued by operation. It lias
been frequently proposed, even urged, first by Rogers, as the only means
of rescue for one of the most deplorable and overwhelming accidents which
can befall a woman. Twice the author has been on the point of perform-
ing it, but was restrained by scruples as to the diagnosis ; in both cases a
post mortem justified the belief that the patients might have been saved.

Extra-uterine pregnancy in its more advanced stages need not detain
us, except in regard to two points. The author's detailed experience with
cases of pregnancy with thin uterine walls, which were supposed to be
extra-uterine, is extremely interesting and instructive. Six times he has
been called to such cases where the question was as to the child being free
in the abdominal cavity, and in all in due time delivery took place natu-
rally. He justly says that this point has not yet received the notice it
deserves by obstetrical writers. In cases where the cyst is packed down
in the pelvis, and diagnosis is difficult, the author strongly advises against
the use of the aspirator, being no more friendly to this instrument than to
the sound.

" The aspirator may tell you that a tumour contains serum, blood, or pus, but
that helps you but little as to the seat of the disease, and nothing at all as to its
treatment. Besides, the risk of the aspirator is great, quite as great as the risk
of an abdominal section. My use of the aspirator in my special line of practice
is, therefore, diminishing, and in all cases of abdominal tumour, where there
seems a reasonable prospect of doing good to the patient, I open the abdomen
and make out the condition. I have never had to regret the j)ractice, and I very
often have had reason to be pleased with its results."

It is in connection with this subject of extra-uterine pregnancy that we
experience the greatest disappointment as to the book. The subject of
early diagnosis does not receive that consideration which it deserves, in-
deed, scarcely any mention at all. Truly, he says, the diagnosis in the
early stages "is surrounded with difficulties." Then it certainly should
not be dismissed with about ten lines, nor the statement made that the
only conditions1 from which it is to be differentiated, are displacement of
the normally pregnant uterus during the early months, complicated with
fibro-myoma or cystic disease of the uterus, and, more rarely, pregnancy
of one-half a double uterus. We will not doubt that with the author's
diagnostic powers these are all; but, for the benefit of readers less gifted,
other conditions likely to, and which not infrequently do, cause doubt and
anxiety, should have been considered. Two prominent symptoms have
been held to indicate, even to be pathognomonic of, extra-uterine preg-
nancy in the early stages : severe attacks of pain in the pelvis accompanied
by a sanguineous discharge, and the discharge of a decidua. These are
not even mentioned by the author, and not having considered an early
diagnosis it is not surprising that there is nothing said of treatment before
rupture. Neither puncture of the sac with injection of narcotics, or the

1883.] Pathology and Treatment of Diseases of the Ovaries. 177

application of electricity, to destroy the life of the foetus and prevent dis-
aster, receive a word of notice I Yet if we are to do the best for these
cases it is to be done early. The omission doubtless results from the man-
ner in which the book has been built up, and here, as elsewhere, we regret
the lack of that fulness of detail which a subject would have received had
it taken the form of a treatise.

The changed vascular conditions of the ovaries brought about by puberty
have their legitimate pathological consequences, and, while much relating
to inflammatory affections of these organs yet remains obscure, the author
felicitates himself upon the fact that our knowledge is being rapidly in-
creased, the result of more frequent operations for diseased conditions
other than cystoma. He treats of hyperemia, and acute and chronic ova-
ritis. Menorrhagia is very frequently the expression of the first, the
result of an over-sufficient and precocious ovarian activity. Stimulated
by the over-refinement of our civilization, menstruation is established

while the ovary is still in its infantile or incompletely developed condi-
tion ; " that is, "•while it is forming incomplete cells, whose nuclei
are incapable of fulfilling their great functions." These cases de-
mand regulation of life in every respect, and the author is out-spoken
in regard to the injurious influence of the study of music. He is
sound on the deleterious effect of iron in these cases, and this seems to
be there, as it is here, one of the most common of therapeutic sins. For
acute ovaritis he recognizes five causes : injury, gonorrhceal infection,
puerperal septic poisoning, exanthematic fevers, and acute rheumatism.
Some of the author's remarks here on etiology and pathology are exceed-
ingly interesting and of great practical value. Further experience and
observation have confirmed him in the belief of the influence of the exan-
themata, and especially smallpox and scarlet fever, in producing inflam-
mation of the ovaries. But, he believes the inflammation distinct in char-
acter from the ordinary form. In the latter the peritoneal covering is
affected and it should be termed peri-oophoritis, while the exanthematic
inflammation is interstitial, affecting the follicles. In the one menstrua-
tion is not suppressed and may be profuse, in the other we have ovarian
atrophy with amenorrhoea, and in puerperal cases superinvolution of the
uterus. Chronic ovaritis produces hypertrophy of the glands, and of this
there are two forms, one affecting the follicles of the gland, the other its
fibrous tissue. This follicular hypertrophy does not form the ordinary
cystoma of the ovaries. The organs are but little increased in size, yet,
in the author's opinion, there is "a close and hitherto unsuspected con-
nection" between this form of disease "and some of the most severe ute-
rine symptoms that patients suffer from." In any event, such ovaries are
frequently the cause of severe menorrhagia, which nothing but their
removal will control. Abscess of the ovary is a rarer result of chronic
ovaritis, yet cases are given.

This is but the briefest possible sketch of the author's views as to this
branch of ovarian and tubal pathology, but indicates the basis of some of
. his operative measures. These cases are characterized by pain, menstrual
and inter-menstrual, by uncontrollable menorrhagia, by dyspareunia to
an extent that renders intercourse impossible, and the patient sinks into
confirmed invalidism. Then surgery presents relief by removal of the
organs which are the cause and origin of the suffering. It is not "nor-
mal" ovariotomy, for the organs are always diseased, and the author makes
the powerful plea, that in performing this operation, the surgeon does not
No. CLXXI July 1883. 12

178

Reviews.

[July

unsex the woman, as has bee*i urged in opposition to the measure, but
really resexes her — enables her to resume relations with her husband,
which had Ion"; been impossible. Many cases are detailed in full, illus-
trating these different phases of disease and supporting the author's posi-
tion.

The fourth chapter of the work is on Ovarian Tumours and the condi-
tions which simulate them. It consists of about one hundred pages, of
which more than one-half is devoted to the pathology of these growths.
There is no lack of interest in this part of the book, for here again the
author has original views based on his own investigations, but much of
the chapter is argumentative, some of it is taken up with details of cases
of the rarer forms of tumour. We can only give the leading points of
doctrine, and are obliged to confess that some portions are not clear, and
feel sure that the reader will regret the lack of a plain and tabulated
classification at- the outset. He opens with an expression of dissatisfac-
tion at the many important questions yet remaining, as they were in l*7-*3.
unsettled. In the papers of De Sinety and Menassez, published in 1878,
he finds confirmation of many of his views, but still is far from being in
harmony with them upon all points. His leading divisions of ovarian
tumours are cystomata, dermoid, and parovarian. In regard to the first,
he rejects the doctrine of De Sinety, that they have their origin in the
tubes of Pfliiger, and denies that they are growths of the connective
tissue of the gland, maintaining that they are always the result of
dropsical distension of the Graafian follicles. " The function of the ovary
is one of cyst formation from its earliest existence to its latest, and in its
pathology we need not go far away from its physiology." He rejects t lie
term " proliferous," as defined by Wells, in the sense that the secondary
cysts are outgrowths from a parent cyst. They are secondary only so far
as date of growth is concerned, " but they are the younger brothers and
sisters, not the children, of the larger sacs." Dermoid cysts, on the
other hand, are the result of an altered nutrition of one or more ova.

"But there may be doubt as to whether the abnormality takes origin in an
ovum of the individual bearing the tumour, or in the ovum from which she her-
self was developed ; in other words, whether the tumours are abnormally de-
veloped, or are due to inclusion."

The author supports this doctrine by arguments drawn from compara-
tive physiology — dermoid cysts originate by a process analogous to patho-
genesis.

The origin of parovarian cysts is plain and simple, but we have the
new and important doctrine introduced and emphasized that they alone
constitute the unilocular tumours w7hich are called ovarian. The author
does not believe in the existence of a unilocular ovarian cyst. Such a
thing is not consistent with his doctrine of the origin of cystomata, and
by observation he has learned that in all these cases of monocysts the
ovary may be found, if sought for, separate and distinct from the tumour,
or spread out on its walls.

"In the records of ovariotomies performed, these cases have, up till now.
always been stated as ovariotomies, and the ovary and tube associated with the
tumour have been removed with it. Both the record and the removal of the
ovary are mistaken [?]. The operation is not an ovariotomy at all, and nine
times out of ten both ovary and tube might easily be separated from the tube
and left, and this practice I now always try to follow."

1883.] Pathology and Treatment of Diseases of the Ovaries. 179

Then he comes back at his critics !

"It is very curious that those who are crying out most loudly against the un-
necessary removal of ovaries have been in the habit of pursuing this practice in
the case of parovarian tumours without compunction."

The author's remarks upon the connection between ovarian cystic dis-
ease and cancer are of great practical interest. It is difficult to follow
him through the minute pathology of malignant degeneration, and we
are compelled to say that, from repetition and want of clear arrangement,
his views are by no means easy to get at. The origin of the process is
in the epithelium, and he quotes De Sinety in support of his position.
The epithelium of an enlarged follicle is very different from that of one
of normal size. There is a reversion of type of the cells " towards im-
mature, incomplete, and rapidly growing elements which are practically
cancerous."

Then follows a statement which needs confirmation, and should have
been supported by statistics, instead of the recital of a single case : —

"As a matter of fact, ovarian cystomata are a great deal oftener malignant
than has yet been admitted. The recovery from an ovariotomy is generally so
rapid and easy that at the end of a month we say 'cured,' and discharge the pa-
tient. But a number of these ' cures' die speedily of cancer of the peritoneum,
or of other organs, and the more our primary mortality from the operation has
diminished, the more numerous have become these secondary deaths from cancer,
occurring between three and thirty months after the operation."

The author then refers to the clinical fact " which all ovariotomists are
quite familiar with," and to which, he says, Keith has drawn especial
attention — " that the rupture of certain cysts, on the escape of their fluid
into the peritoneal cavity, is followed by, or at least associated with, the
infection of the general peritoneal surface with papillary cancer."

He then strengthens [?] his doctrine of the connection between the
two by saying : —

" On the other hand, I have seen over and over again the same cells and the
same expressions of immature growth in the peritoneum, without the presence of
any ovarian tumour !"

The practical conclusion has been reached by others from other
grounds : —

"The conclusion from all this is that to which I have already pointed, that
the growth of ovarian tumours is associated with a tendency toward malignant
disease, which finds constant clinical expression, and which receives its explana-
tion in the marvellous changes we find produced in the epithelial linings of its

cysts One thing I am certain it clearly establishes, and that is the

absolute propriety of removing ovarian tumours at a very much earlier stage of
their existence than has been, till recently, the accepted rule in practice" If
these epithelial changes are progressive — as doubtless they are, and if they are
malignant — as I certainly believe them generally to be, then, acting upon the
principles which guide us in the treatment of all tumours, we ought to remove
an ovarian cystoma early in its history, before these changes have been effected,'
and certainly before there is any risk of cyst-rupture."

The changes in the epithelium are not alone in one direction or of one
character — there is no kind of cell of epithelial origin which may not be
found in the cysts of an ovarian tumour. Upon this ground Mr. Tait
rejects entirely the doctrine that a diagnosis of such tumours can be based
upon any particular kind of cell found in their contents. He has no
faith in Dr. Drysdale's " ovarian corpuscle."

180

Reviews.

[July

The diagnosis of ovarian tumours, direct and differential, is not pre-
sented in a satisfactory manner, especially when we consider the large
experience which the author has enjoyed. While the practitioner will
peruse this portion of the work with deep interest, and derive profit
therefrom, it is far from being adapted to the wants of the student. It
lacks in methodical arrangement and clear statement, in comparison and
antithesis ; and, moreover, is far from being complete upon some very
important points. We should be sorry to do injustice to so distinguished
an author, and therefore feel compelled to specify. Upon the differential
diagnosis of pregnancy, there is no mention of the mammary signs. We
have already noted the lack of consideration of the rational symptoms of
extra-uterine pregnancy; here we expected compensation in a full and
minute detail of the physical signs. All we have is this !

"If the uterus is drawn up very much in front, and the posterior lip seems to
be lost upon the tiimour, then we may expect a tubal pregnancy."

What the following means in regard to the differential diagnosis of
ascites we cannot understand : —

" Ascitic fluid may be generally recognized by the fact that it is associated
with the uniform occurrence of a tympanitic note on percussion."

In regard to the value of hemorrhage in the differential diagnosis of
myoma, on page 190, he says, that with ovarian tumours this symptom
has been " repeatedly noticed in my practice," while, on page 21G, we
read that it is a " most constant clinical feature characterizing myoma,
which is seldom met with in ovarian cystoma."

There is one great unsolved point in the diagnosis of abdominal tumours,
and that is to differentiate an ovarian cyst from fibro-cystic tumour of the
uterus. The author acknowledges one mistake, admits the difficulties of
the diagnosis, and says that "a correct diagnosis is possible only in the
hands of a surgeon who had made two or three previous mistakes." Then
we submit that the following is but a scant measure to be meted out to so
important a point : —

" The tumour will be found associated with the uterus, the latter moving along
with the tumour when it is moved, and bping dragged upward by it to an extent
that ought always to make us cautious and warn us to watch and wait."

The practitioner will find in the author's narrative of cases profitable
reading and food for reflection. He inculcates the utmost care and the
closest investigation, repeated again and again, if need be, before making
a diagnosis. He urges the importance of patience; many a case is cleared
up, and many a blunder avoided by the lapse of a little time. Nothing
could more strongly impress these lessons than the errors which he can-
didly confesses, for where one with so large an experience has gone astray
how easy for others. He records in this chapter one case of fibro-cystic
uterine tumour operated on for parovarian cyst ; says he has " more than
once opened an abdomen under the complete belief that I should find an
ovarian tumour, but have instead found only masses of cancer, with an
abundant ascitic effusion ;" on " several occasions" he has proceeded to
perform ovariotomy, and found tumour of the kidney; and once a tumour
of the liver presented itself. Those only who have no practical acquaint-
ance with the difficulties of the subject will carp at such confessions.

The author's experience with and remarks upon phantom tumours,
spurious and real pregnancy, hydramnios, and hydatids are exceedingly

1883.] Pathology and Treatment of Diseases of the Ovaries. 181

instructive. Of the latter he has seen four cases, but has .never met with
the peculiar fremitus which is said by some to characterize the tumour.
In regard to pregnancy he places a very high value upon the contraction
test, even estimating it above auscultation.

" If the hands be placed on the abdomen of a case of suspected [?] pregnancy,
and a fluctuating tumour be felt, that, tumour will become quite tense and like a
myoma, if the examination be prolonged for a few minutes. Then, again, it
will become flaccid and fluctuating, and this alteration will go on rhythmically
at varying intervals. Once this sign has been felt and recognized, I think it will
be impossible for the observer ever again to be deceived by a pregnant uterus."

It will be seen that the sign is spoken of as a constant one ; nothing
is said of exceptional cases, or of conditions interfering with observation
of it. However, this much is certain, the author has the prime element
of a first-class diagnostician — a high estimate of the value of, and confi-
dence in, the sense of touch. His remarks on fluctuation and its detection
are excellent.

In the chapter on ovariotomy we are brought directly in contact with
the practical work of the author, and face to face with some of the most
important surgical questions of the day. The time to operate is, for the
author, as soon as the tumour is discovered, and this is rapidly getting to
be the general practice, and has been ably advocated by Mr. Bantock.1
He claims to make no selection of cases, however advanced a case may
be; " even when there is strong reason to believe that the tumour may be
complicated with malignancy," he makes an exploratory incision : —

"An exploratory opening never does any harm [?], and very often does a
great deal of good. . . . We sometimes see an exploratory incision arrest the
progress of an irremovable tumour for a considerable time."[?]

" I should not hesitate to operate in a case where there were even distinct in-
dications of important visceral disease. I have operated on two patients with
marked disease of the lungs, and they are both still alive, and one has got nearly
well. I have operated in an advanced state of Bright' s disease, and the patient
recovered."

As to who should perform the operation he makes a strong plea for
specialists. No man in attendance on promiscuous cases, no man who
has not seen a good deal of abdominal surgery should operate. The cases
are too few, while the lessened mortality obtained by experienced hands
is too apparent to justify every one in undertaking it.

In preparing for the operation he inculcates, as he does in diagnosis,
the minutest care and the closest scrutiny of every point. He expresses
the same estimate of the magnitude of little things that Emmet does in
the practice of gynaecology :

" As a successful ovariotomy is the resultant of a large number of petty details
carefully attended to, no amount of care and precision can be too great in carry-
ing them out."

As to the sponges, whoever reads his graphic account of that thirteenth
sponge will never forget the lesson ! He states that he has heard of ten
other cases in which a sponge has been left in the abdominal cavity!

The author is no more a friend of tapping, as a curative measure, than
for diagnostic purposes. His opposition to the measure is extreme, and,
we are obliged to add, unreasonable. It is not alone for ovarian cystomata

1 A Plea for Early Ovariotomy. London, 1881.

182

Reviews.

[July

that he opposes it, but for parovarian cysts as well, which " are now re-
moved without any risk at all. I have never lost a single ca-e.*'

" Here I may repeat what every one knows now, that it never cures a
tumour, [?] and that it only brings about complications. It is my firm belief
that, if ovarian and parovarian tumours were never tapped, but were removed
early in their history, we should have only a casual mortality from the operation
of ovariotomy."

In this he is in accord neither with Keith,1 whose apostle he is, nor
with Wells,2 whose apostle he certainly is not, nor will he be followed or
believed by any one whose even much more limited experience has fur-
nished an instance of a cure by tapping. " There is an impression abroad,"
Mr. Tait says in another place, " that these cysts are occasionally cured
by tapping." Doubtless, Clay laboured under such an impression after
he had forty cases cured by a single tapping;, and only six which filled
again ! 3

Parovarian cysts are not all alike as to their contents, as taught in this
book, as shown by Garrigues.4 May it not be that in those filled with
limpid fluid, tapping will often prove curative, while it will always fail in
those having thicker or more darkly coloured contents.

The three great points of ovariotomy are the treatment of the pedicle,
the antiseptic system, and drainage. In regard to the latter, the author is
very brief, says he has had considerable experience with it, and is con-
vinced that there will occur, every now and then, a case in which it will
be absolutely necessary, but nowhere points out for the benefit of the stu-
dent or the inexperienced, the circumstances which demand it. His re-
marks on the large quantity of fluid which sometimes pours out of the
peritoneum through the tube are interesting. He thinks a healthy peri-
toneum, being a huge lymph-sac, could be made to drain away an indefi-
nite quantity.

" My own view about drainage, is that it will be useful only where some addi-
tion to this lymph-stream is made greater than the outlet can carry away. The
fact that I have been so successful in my operations without drainage, makes me
think it probable that I have unconsciously substituted purgation for drainage ;
for, on looking over my records, I find that in very many of the cases where Dr.
Keith would have drained, I have purged. . . . But it will remain for some
time an open question which of the two channels, the drainage-tube or the intes-
tinal canal, will prove the better vehicle."

It should have been premised, that in after-treatment Mr. Tait does not
take any great pains to keep the bowels quiet, and even resorts to cathar-
tics without hesitation.

In the treatment of the pedicle Mr. Tait uses the ligature almost ex-
clusively— the ligature cut short and the abdominal wound closed. For
this, since it is supported by abundant success, he deserves the highest
praise. As it required great moral courage on the part of Keith to break
away from the clamp, supported as it was by the high authority and im-
mense experience of Wells, so it required strong convictions and firm
confidence in them, to depart from Keith's plan with the cautery, and
adopt any other. Yet Mr. Tait has done it, and thereby ovariotomy has

1 American Practitioner, Nov. 1881.

2 Ovarian and Uterine Tumours. London, 1882.

3 Peaslee, on Ovarian Tumours, p. 100.

4 Amer. Journ. Obstetrics, Jan., April, July, 18S2.

1883.] Pathology and Treatment of Diseases of the Ovaries. 183

been improved, for an operation approaches perfection as ,it is increased
in simplicity. The clamp he uses only in very exceptional cases.

"Probably not more than two or three cases in a hundred .require now to be
dealt with by the clamp ; certainly I have not met with more than one for the
last three years. The kind of pedicle requiring the clamp is thick and soft, and
so short as to contain, perhaps, a small piece of the tumour. With such a pedicle
the extra-peritoneal method is admissible, and probably is superior to treatment
either by the cautery or ligature ; but I am not quite sure that a combination of
a drainage tube with either of these latter methods may not yet be found superior
to the clamp."

He has devised a clamp which may be termed a wire-constrictor, and
has used it " in thick pedicles in eleven cases with perfect success, and six
of these were uterine myomatoma." But, for general use, he not only
rejects the clamp, but believes it to have been decidedly injurious, both
as to the rate of mortality and the progress of the operation. He enters
into a somewhat elaborate history, if elaborate may refer to the number
of pages occupied, of the different steps by which the operation has ad-
vanced to its present position. Nathan Smith, in 1822, was the first to
cut short the ligature, return the pedicle, and close the wound. But this
Mr. Tait would belittle by calling it a parovarian cyst, and no ovariotomy
at all, and this he does of the majority of the early operations. This is
scarcely fair. To enter the abdomen was at that time a greatly dreaded
proceeding ; moreover, it is only a later pathology which has established a
distinction between the two kinds of tumour. Therefore, those who were
bold enough to operate deserve all the honour they have received. To
Clay belongs, in his opinion, the larger share of the credit of giving the
greatest impulse to abdominal surgery, and thinks that if he had abandoned
the long ligature his mortality would have dropped to present limits.
Next to him he places Baker Brown, with his treatment of the pedicle
with the cautery, and singularly enough, does not mention Tyler Smith,
although, some forty pages further on he quotes from Mr. Doran, that he
was " the first authority who regularly and systematically advocated com-
plete intra-peritoneal ligature." Then came Wells with the clamp, and
after him Keith, who based his brilliant success on four points : drainage,
the cautery for the pedicle, compression forceps, and ether. After review-
ing and comparing the mortality of the different operators, the author
says : —

" . . . The introduction of the clamp was a decidedly retrograde step in
the history of ovariotomy. When I began my own practice in 1867, I employed
the 6craseur, a variety of the intra-peritoneal method, and my results over a
limited experience were extremely good. Like others, however, I was so im-
pressed with the overwhelming experience of Mr. Wells, that I resorted to the
clamp, and my results with it were so bad, that its employment will ever be to
me a matter for bitter and lasting regret."

Minor's plan of enucleation has been resorted to by the author three
times, but he thinks it by no means easy of performance, and says it always
gives rise to hemorrhage.

It should be stated that of a series of one hundred cases treated with the
ligature, and without antiseptics, only two proved fatal! "and in both
cases death was due to the fact that they had been repeatedly tapped."

The most interesting and the most important part of this work is that
in which the author sets forth his theory and practice in regard to the
antiseptic system of surgery. If all the details of Listerism are unneces-

184 Reviews. [July

sary, then they should be abandoned, if for no other reason than as being,
one and all, a departure from that simplicity which is the measure of per-
fection in operations. Mr. Tait believes them to be not only useless, but
injurious. But, first of all, he fully recognizes the potent influence of
septic poisoning ; and emphasizes the necessity of avoiding infection, in
language which cannot be made stronger : —

" There is no operation in the whole range of surgery where the patient seems
to be so apt to be infected by septie influences, and no precautions against them
can be too great. For any surgeon to perform an ovariotomy while he is engaged
in dissection or in the performance of post-mortem examinations, or while lie is
attending any case from which he may be likely to convey septic infection, should
therefore be looked upon as a professional oifence of the gravest kind."

"... In my opinion any man who deliberately performs an operation
under circumstances from which his patient acquires fatal blood-poisoning ought
to be the subject of a criminal indictment."

The germ theory of putrefaction is fully accepted to this extent, that no
process of putrefaction occurs without the admission and presence of germs
or species of the minute living organism, which are always found asso-
ciated with the putrefactive process. But thence the author makes a wide
departure. It is only in dead tissue that these germs are operative ; they
have no power over the living.

"... No one has yet pretended that, by the admission of germs to living
matter, he has produced the phenomena of the putrefactive changes which con-
stantly result in matter which is dead."

" . . . There is not the slightest particle of evidence that they [germs]
do produce any change whatever upon living tissue, still less is there any evi-
dence that the changes which occur in the numerous varieties of what we call
blood-poisonings, even when they are undoubtedly of a local origin, have the
slightest analogy to those seen in a putrefying de'ad infusion."

He then makes the powerful argument that if these germs, so numerous
and so ubiquitous, were the cause of septicaemia and death, these results
would necessarily follow any solution of continuity of the skin, and that
there would be some approach to the ratio of mortality between minor
and major operations as there is not now.

"Amputations of the finger and of the thigh ought to have approached one
another in mortality to an infinitely larger extent than they have done."

"The ordinary hypodermic syringe will inculcate inevitably a sterilized solu-
tion of dead organic matter, but amongst the hundreds and thousands of hypo-
dermic injections which are made daily no one has yet declared a single instance
of putrefactive changes resulting from it in the healthy, or even in the diseased
human body."

" The slightest cut of the skin ought to be followed by septic poisoning. There
ought to be no difference in the mortality of operations in small and in large
hospitals in town or country. In fact, if germs could have had the unbounded
influence which is claimed for them by many antiscepticists, surgery must long
ago have been an extinct art, if, indeed, it ever could have struggled into
existence."

But the author does not merely enter a verdict of " not proven" as to
the antiseptic system. He opposes it and charges upon it, as some others
have done, direct injurious influences. He has seen one case of death
which he attributes to thymol, one to carbolic acid, and dangerous symp-
toms in several. He quotes and endorses Keith to the extent that Lister-
ism will add two or three per cent, to the mortality of ovariotomy. He
finds other less obvious sources of evil. A belief in the efficacy of anti-

1883.] Pathology and Treatment of Diseases of the Ovaries. 185

septics will lead to the undertaking of the operation by hands bathed in
purulent or septic fluids; others will be seduced into doing it by the
fulness of its promise as a royal road to surgical success ;" but " even an
antiseptic spray will not condone the want of manipulative dexterity, or
the absence of readiness in emergency."

There are three factors of success in operative surgery, the condition of
the patient, his surroundings, and the nature and the extent of the opera-
tion performed. It is in this trinity, the author maintains, that the varying
mortality after operations finds its explanation.

How, then, is the wonderful success in ovariotomy which followed the
introduction of Listerism to be explained? As to Mr. Keith, with his
eighty-odd consecutive recoveries, as he himself has abandoned the spray,
we need not stop to explain. Mr. Tait disposes of Spencer Wells and his
statistics. It has already been seen that to the introduction and use of
the clamp by Mr. Wells is charged the maintenance of a high rate of
mortality after ovariotomy, and a retardation of the progress of the opera-
tion. Mr. Wells abandoned his faulty mode of treating the pedicle at the
same time that he adopted the antiseptic system, and, according to the
author, it is to the former instead of to the latter fact that his increased
success is due.

" Nearly concurrently with his [Wells's] adoption of germicides he adopted
the intra-peritoneal method of dealing with the pedicle, a method which has
been superlatively successful in the hands of Dr. Keith, and to which, chiefly, I
attribute my own rapidly increasing success. Thus, Mr. Wells's mortality im-
provement argues nothing in favor of antiseptics, but far more, in my opinion,
for the short ligature."

;,Mr. Wells . . . now attributes his diminished mortality to the intro-
duction of antiseptics. There is this difficulty, however, left for him to explain :
his mortality now is double that which Dr. Keith had secured before he used
antiseptics at all, and at a time when Dr. Keith's experience was little more than
a fifth of what Mr. Wells's is at present."

It is evident, in this book as well as elsewhere, that Mr. Tait does not
like Mr. Wells or his methods.

The author, then, uses no antiseptic measures as generally understood,
neither spray nor carbolic acid, nor thymol ; simple cold water in which
to place his instruments and ligatures, and this is all ; and this only as "an
easy and effective method of keeping them clean." It remains now to
give his success with and without antiseptic measures, for, of course,
volumes of theory are valueless compared with actual results obtained.
We are compelled, therefore, to complete the argument, and, in justice to
the author, to present the following table of the entire results of his practice
up to the time of writing : —

Cases. Mortality.
Non-antiseptic ligature . . . 187 3. 74 per cent.

Antiseptic " . . .52 3.84 "

Clamps — non-antiseptic ■ . . 36 25.00 "

" antiseptic .... 26 27.00 "

Under the head of antiseptic ligature it is stated that there were twenty-
two consecutive recoveries, but in them the Listerian process was not
complete, only dry cotton-wool being used for dressing. If these cases
had gone badly, he justly says that the antisepticism would not have been
accepted. Placing these then with the non-antiseptic cases, and it gives a
mortality of three per cent., and leaves to the antiseptic class 30 cases,

186

Revtews.

[July

with a mortality of 6.6 per cent. In a table at the end of the chapter are
given full particulars of each case — as residence, date of operation, name
of medical attendant, etc., which preclude all cavil as to reliability of the
statistics.1

Mr. Tait's judgment and practice as to anaesthetics will naturally be
looked for with the deepest interest by every operating surgeon. He de-
votes considerable space to the subject, and his decision is strongly in
favor of ether. His mode of administration is the simplest possible — by
dropping on a single fold of towel laid on the patient's face. The only
objections to this plan are the minor one of waste of material, and the
major one of covering the countenance, which should always be watched
during the administration of an anaesthetic. Singularly enough, his ex-
perience as to the far less amount and frequency of vomiting after ether as
compared with chloroform does not accord with Keith's; and as he has
not found so much sickness after other operations, he believes that the
constriction of the pedicle has something to do with this symptom after
ovariotomy. He states the number of administrations at between five and
six thousand, and in a foot-note states that he has had one accident.2

He recognizes fully the danger of bronchitis to old people, and has
devised and figured an inhaler for warming the vapour as it is adminis-
tered. The apparatus is certainly cumbrous, and the end is better at-
tained by Clover's lesser inhaler. In addition, we suggest, that it is
bare assumption that temperature is the only element of danger in these
cases. It is singular, too, that over fifty pages of the book intervene
between consideration of ether and the following paragraph, which we
should certainly move up in juxtaposition : —

" Once or twice, after the removal of very large tumours from elderly women.
I have seen a short, rapid cough set in, rapidly increasing in severity, and killing
the patient in about thirty hours. What had occurred was, I believe, perfectly
analogous to the suffocative catarrh of old age."

There is no mention of a hypodermic injection of narcotics preceding the
anaesthetic. If there was, we think that straps to bind the patient's arms
and legs to the table would not be among the preparations for operating.
We have no statistics that will make any approach to those of Mr. Tait,
but so far as they go, they would scarcely show an instance of a patient
ever moving an extremity during ovariotomy.

The sixth and last chapter, the shortest of the book, is by no means the
least interesting or important. It is on "Recent Extensions of Abdominal
and Pelvic Surgery," and gives an account of the author's operations in the
abdomen other than ovariotomy. Chief among these is "removal of the
uterine appendages." Extirpation of the ovaries alone he limits to a very
narrow line of cases. This is " Battey's operation," or " normal ovari-
otomy," to both of which terms he objects, to the latter especially as tend-
ing to encourage the misrepresentation that healthy ovaries are removed
upon very slight grounds. This operation he would restrict to those cases
" in which there is no physical evidence of pelvic disease, yet where there
are serious symptoms so intimately associated with menstruation as to

1 In a paper published in the British Medical Journal, February 17, 1883, giving an
account of two hundred and eight 'consecutive cases of abdominal section, the mor-
tality is : for exploratory incisions and incomplete operations, 5 per cent. : for ovarian
and tubal operations, 112 cases, 2.6 per cent. ; for removal of uterine appendages, 39
cases, 12.8 per cent.

2 The reference is to British Medical Journal, July 14, 1882.

1883.] Pathology and Treatment of Diseases of the Ovaries. 187

lead ns to believe that an arrest of that function might cure or relieve the
patient by the establishment of a premature menopause." Thus far this
class includes but five cases, all for one disease — epilepsy. When it
comes to operating for intractable hemorrhage, the author lays stress upon
the removal of the Fallopian tubes as well as the ovaries — all the " appen-
dages" are taken away; and this is the novelty of his operation, and for
which he claims credit. He believes, indeed, that " removal of the Fallo-
pian tubes is more important than removal of the ovaries, and in by far the
larger number of my cases that alone might have sufficed ; indeed in many
it has done so." For hemorrhage caused by uterine myoma he therefore
rejects hysterectomy and enucleation, quoting Duncan and Gusserow that
the mortality of the former is seventy per cent., and of the latter fifty. He
rejects, too, palliative treatment by intra-uterine injections of styptics, and
we are not surprised, for he has had "three deaths from it in some ten or
eleven cases!'1' Removal of the ovaries and the tubes is comparatively
safe, atfords a security against relapse, which enucleation does not, and
avoids the dangers of extirpation of the uterus. Of this class he reports
forty-five cases, giving all particulars necessary for verification, with two
deaths.

The next class consists of cases of hydro- and pyo-salpinx, the pathology
of which has already been given, the importance of which has long been
recognized, but for which, until now, no rescue has been offered from the
severe suffering and prolonged invalidism they entail. Of this class forty-
five operations are reported, with two deaths.

' 1 The operations are generally very difficult, for it is quite exceptional not to find
the tubes and ovaries densely adherent to the viscera and the pelvic wall, and in some
the difficulty in overcoming these adhesions has transcended anything I have ever
seen in the removal of cystic tumours of the ovary. In some cases the hemor-
rhage during the operation has been alarming In three of the cases

the diseased organs have been removed only at a second attempt ; that is, in my
early practice I had not the courage and necessary dexterity to complete the ope-
ration In one case I made three attempts to remove the tubes, the

third being successful."

This operation, therefore, will probably not be abused as some others
in gynaecological practice have been by that large class who, with a thirst
for notoriety, rush in where better men tread with circumspection.

Then follow two tables of forty-four cases of removal of the uterine ap-
pendages, for hydro- and pyo-salpinx, all successful.

The author's experience with hysterectomy extends to eight cases, dates,
and names given, all successful. He contrasts this with Mr. Wells's sta-
tistics as given in his recent work, thirty-nine cases, twenty deaths, and
attributes his results to the treatment of the pedicle with his wire clamp
instead of with the ligature. For uterine exsection the ligature is as bad
as it is good in ovariotomy.

''It seemed to me more than curious to see Mr. Wells deserting the clamp in
.the very field where its use is promising to be an advance, after he had used it for
twenty years in a field where it was a detriment and a hindrance to all progress.'"'

Next follows a list of other operations, without particulars, which shows
wonderful results. There are 8 nephrotomies, 10 hepatotomies for hyda-
tids, 20 laparotomies for pelvic abscess, 10 for peritonitis, acute and
chronic, 7 for extra-uterine pregnancy, and others, in all 65 cases with
one death !

188

Reviews.

[July

" By no means the least satisfactory groups in the above list are those of acute
and chronic peritonitis. In these cases absolute cures have been effected in every
instance, by the simple plan of opening the peritoneal cavity, cleaning it out, and
draining it for a short time."

Looking over these results, so brilliant, reading, as we do in one place,
that three times, in performing ovariotomy, his knife has gone through the
bladder, yet the viscus has been stitched up and no harm resulted, the
suggestion rises that the operator must have 'some charmed talisman.
Surely he wears the cap of Fortunatus ! A genial friend suggests that
henceforward the Japanese must abandon their time-honoured customs —
hari kari is no longer a dangerous process !

Based upon such an experience and supported by statistics the author
is justified in the tone of exultant confidence with which he presents the
following : —

" So fearless am I now of abdominal surgery, so splendid have been my results
in fields of practice which, until three years ago, seemed hopelessly inclosed, that
1 venture to lay down a surgical law, that in evert/ case of disease of the abdo-
men or pelvis in which the health is destroyed or life threatened, and in which
the condition is not evidently due to malignant disease, an exploration of the
cavity should be made."

We have aimed to present the author's surgical work, his methods and
results, rather than to criticize the book in which they are laid before us.
We are obliged to say that in many respects it is not above criticism.
That it will receive it there cannot be a doubt, for Mr. Tait himself is not
a mild critic, and when he charges upon the surgeons of a hospital of
world-wide renown, as he does on p. 153, the killing of a patient, both by
direct and indirect measures, he must expect the returns that such charges
always excite. Allusion has been already made to the blemishes inevita-
ble from the manner in which the book has been made up, by patchwork
added to a former essay. Nor would we be severe upon this point, for the
profession is too much indebted for the publication of experience by busy
men like the author, and ought to welcome it upon any terms. When,
however, important practical points are left obscure, or even directly op-
posite statements made in regard to them, the case is different. As
instances we refer to the ambiguity if not widely different opinion as to
the significance of bilious vomiting after ovariotomy. Take also the fol-
lowing as to temperature and pulse after the same operation : — .

" I attach less value to the temperature curves than to the pulse curves." — p.
279.

" There are many dangers in the path of every patient submitted to this ope-
ration, and there are many indications of their approach, but none so trustworthy
as those derived from a close observation of the patient's temperature curve." —
p. 313.

There is about a page on each subject to the same intent of which, for
want of space, we give only a specimen sentence.

We should be less than human did we fail to say a few words in vin-
dication of our countrymen. Dr. Battey's claims seemed first to demand it.
It is well known that the operation known by his name was performed by
two other surgeons, Hegar and Mr. Tait, a very short time before he did
it, but that he preceded them both in publication. On page 107 we have the
direct statement that " Dr. Battey's publication was also subsequent to
both of ours." On page 326 we have the equally direct statement that
" Dr. Battey was the first to publish his cases, and a defence of his pro-

1883.] Pathology and Treatment of Diseases of the Ovaries. 189

ceedings, 1872, while I contented myself with discussing the principle
only in my Hastings Essay, 1873." So Dr. Battey stands vindicated!

Again, Mr. Tait gives a sketch of the history of ovariotomy which is
partial, partisan, and unjust beyond measure. Not a word is said of any
operator on this side of the Atlantic after Nathan Smith. He does
not mention the name of Atlee, who began operating as soon as Clay,
and whose tables and suggestions it suited a London surgeon to publish
as his own. It is no less than an attempt to rob this country of the
honour of being the birth-place of ovariotomy, and to deny to Ephraim
McDowell the merit of having made this great advance in surgery.
Houston, of Glasgow, is the one who, according to Mr. Tait, was the first
to successfully remove a diseased ovary! He prides himself upon pre-
senting additional information in regard to Houston, obtained from a
resident of Glasgow. But nothing can go back of or beyond Houston's
own report of his own case, and it was a singularly clear and minute
one for those days. He himself does not head it " removal of an ovary"
but calls it a case of dropsy in the left ovary cured by a large incision
made in the side of the abdomen ! Mr. Tait's argument presents some of
the most striking instances of special pleading we have ever encountered !
Thus, he insists that Houston must have tied the pedicle because he says
the tumour was on the left side ! Yet Houston himself says nothing of
seeing or tying a pedicle although his account is so minute that it includes
the number of stitches put in and the kind of bandage applied ! To
Hunter belongs the honour of having first suggested the possibility of ova-
riotomy, yet Mr. Tait would rob him of it to support his claim for Houston.
Hunter, he says, " must have known of Houston's case." Then why did
he not simply say that ovaries could be removed because Houston had re-
moved one, instead of arguing that a woman might suffer spaying as an
animal does? And why does Mr. Tait's suggestion, so ready at hand in
regard to most of the early operations, that only parovarian cysts were re-
moved, fail him here ? And then we read that McDowell was a Scotch-
man ! Born in Virginia, his mother a Virginian, his paternal ancestors
emigrating from the north of Ireland nearly forty years before he was
born, and yet he is a Scotchman !

" My American readers may object that McDowell was not born in Scotland.
Of this, however, we are not yet clear. At any rate his father and mother were
Scotch, and at the time of his birth, 1771, the States did not exist!"

We should have deemed it impossible to be obliged to attach the term
puerile to anything that Dr. Lawson Tait might write, but this is cer-
tainly nothing better than that. And to justify the charges we have made
as to his history, wTe quote the following: —

" It is quite true that McDowell was the first to do a number of ovariotomies,
and it is equally true that Houston was the first successfully to remove a diseased
ovary, but it was Clay, of Manchester, who first showed that ovariotomy could
be made an operation more justifiable by its results than any of the major opera-
tions of surgery!"

And this is written with full knowledge of the fact that McDowell
saved eight cases out of thirteen, and almost on the same page that Clay's
mortality is stated at twenty-five per cent. !

We give all honour to Mr. Tait as a bold and successful operator, and
as a skilful diagnostician, but as a historian he will not bear examination.

J. C. R.

190

Reviews.

[July

Art. XIX Annual Report of the Medical Officer of the Local

Government Board for the year 1881. London, 1882.

Another volume, the eleventh, has been added to this valuable series
of reports. Dr. Buchanan, the medical officer of the board, discusses the
influence of the compulsory vaccination law, and illustrates its beneficial
action by the smallpox statistics of London for the year 1881. In con-
nection with smallpox prevention we learn that a commencement has been
made in the propagation of bovine virus for issue to practitioners from the
National Vaccine Establishment. The original plan of this establishment
provided for the collection of humanized virus by certain approved public
vaccinators, whose operations were to be conducted under supervision, and
the issuance of the matter thus collected ; but in July, 1881, arrangements
were made for the propagation of the vaccine in the calf. Stock from the
Hague was first employed, but in March, 1882, it was given up in favour
of virus from Bordeaux. This lymph is sent out for the commencement
of a local series of arm to arm vaccinations, and physicians using it are
cautioned : —

" 1st. That, as compared with humanized lymph, calf lymph is much less easy
of removal from the 'points.'

" 2d. That such lymph does not 4 take' with the same degree of certainty as
humanized lymph.

" 3d. That the course of the early vaccinations of a series is not so regular as
with humanized lymph."

Bovine points are a more familiar article in the United States than in
England ; and our health officers and public vaccinators have pronounced
in their favour for general vaccination, and not solely for commencing a
series of arm to arm operations. It would be well, however, if we fol-
lowed the example of the English in instituting some supervision over the
production of this important agent in the prevention of contagious diseases.
A bill looking to a warranty of purity by the National Board of Health
was lost during the past session of Congress.

Some interesting investigations into special outbreaks of disease are
reported. Scarlet fever was traced in Halifax to the distribution of milk
from a dairy where the servant, who milked the cows, lived in a cottage
crowded with cases of the disease. In a scarlatinal epidemic in Durham
a distinct interval existing between the cases occurring in the same family
showed that the propagation was by personal intercourse, and not by any
common influence of food-supply, or the like. The establishment of hos-
pitals is urged as the first and most essential of the means necessary to
prevent the spread of the disease.

Typhoid fever at Blackburn was traced to contamination of the water-
supply by oozing from infected privy-pits. At Melton Mowbray a typhoid
epidemic, which appeared to have no connection with the water-supply,
as it was localized in a certain particular part Of the town, was referred to
the choking by floods of a badly ventilated section of the town sewers.
This choking was repeated on three occasions, and was followed each
time, at an interval of two weeks, by an aggravation of the epidemic.

An outbreak of smallpox among rag-sorters at a paper-mill led to an
examination of sanitary and medical literature for instances in which
infection has been communicated by rags, which showed that cases of

1883.]

Report of the Local Government Board for 1881.

191

infection by this means do occasionally occur, although, comparatively-
speaking, not very frequently ; and that smallpox is the' disease most
likely to be thus conveyed.

In view of prevalent rumors of trichinous disease in imported pork the
board issued a memorandum or circular to sanitary authorities throughout
the kingdom insisting on thorough cooking as a means of security against
injurious effects.

" Hams, sausages, and like articles, whether or not they have been smoked or
salted, should never be eaten in the raw state. To be efficient for the required
purpose, the cooking of pork, of hams, of bacon, and of other articles should be
prolonged for about half as much time again as is customary. The smallest joint
should be cooked for not less than an hour ; and whatever be the size of the joint
it should have not less than half an hour's cooking for each pound of meat.
part of a joint that is seen to have an underdone portion in it should be eaten."

In a short time public anxiety was quieted, and the board, with all its
opportunities afforded by its relations with local health authorities, did
not hear of any trichiniasis occurring among the English population.

The propriety of having greater uniformity and comparability among
the forms in use by health officers is shortly discussed, Dr. Buchanan's
conclusions being that the local usefulness of these reports is always the
first object to be sought, and that a uniformity which puts local circum-
stances into the background is not to be desired.

" Conditions of soil or of water-serviee in one district, occupational conditions
in another, circumstances of race or habit in a third, will claim to be more espe-
cially considered in connection with the greater or less prevalence or fatality of

one and another kind of disease Uniformity of tabulation, to the

extent of setting aside a health officer's personal preferences for the sake of serv-
ing a common object, is unquestionably to be sought ; but the end now desired
can, I think, be better attained by health officers in counsel with each other, as
in local societies, than by the appointment, by a central office, of forms profess-
ing to be adapted to all sanitary districts of the kingdom."

The subject of water analysis meets consideration in a paper by Dr.
Cory giving the results of an inquiry undertaken mainly to ascertain how
far some of the processes in common use among chemists, for the analysis
of water, could be relied upon for the detection of dangerous pollutions.
Minute quantities of typhoid excreta and other foul and dangerous matters
were mixed with Lambeth Coy-water, and specimens of the water thus
contaminated were examined by Professors Frankland, Dupre, and Wank-
lyn. A similar investigation was in progress at the time in this country,
conducted under the auspices of the National Board of Health by Prof.
Mallet of the University of Virginia.

The inadequate support given to the board by the national legislature
has interfered with the publication of the details of Prof. Mallet's work ;
but from an abstract of the unpublished report, which appeared as a sup-
plement (No. 19) to the National Board of Health Bulletin, it is evident
that the American undertaking covered a larger field, and entered with
greater detail into the various questions which were opened up during the
progress of the work. The English investigations did not even discover
that urea is broken up into albuminoid ammonia when treated with alka-
line permanganate. In general, the conclusions of the Cory and Mallet
reports are similar. The Frankland or combustion process is considered
to give accurate results so far as the quantities of the organic elements,
carbon, and nitrogen are concerned, but the permanganate oxidations

192

Reviews.

[.July

and the albuminoid process are acknowledged to give valuable and prac-
tically useful information concerning these elements. Nevertheless, it is
found that none of the processes can determine aught concerning the
wholesomeness or unwholesomeness of a given water. The chemical re-
sults obtained from a water polluted with the specific poison of typhoid
fever do not differ from those yielded by other organic pollutions of even a
harmless nature. It is interesting to observe, however, that the English
and American authorities make very different deductions from their similar
results. Dr. Buchanan, in commenting upon Dr. Cory's report, says : —

" The lesson is taught afresh and significantly that while we must ever lie on
the watch for the indications that chemistry affords of contaminating matters
gaining access to our waters, we must (at any rate until other methods of recog-
nition are discovered) go beyond the laboratory for evidence of any drinking-
water being free from dangerous organic pollution. Unless the chemist is well
acquainted with the origin and liabilities of* the water he is examining, he is not
justified in speaking of a water as 'safe' or ' wholesome,' if it contain any trace
whatever of organic matter; hardly, indeed, if it contain absolutely none of such
matter appreciable by his very delicate methods. The chemist can, in brief, tell
us of impurity and hazard, but not of purity and safety.*"

Dr. Buchanan's point of view is that of public health. On the other
hand, Dr. Mallet lays greater stress on the fact that a water need not be
condemned on account of the chemical results of its examination, because
these results may be obtained from harmless organic materials ; his point
of view being rather that of the water companies and moneyed interests.
Thus he says : —

"It will not do merely to throw all doubts on the side of the rejection of a
water, as has been more or less advocated by writers on water analysis, for there
are often interests of too serious character involved in such rejection to admit of
its being decided on. save upon really convincing evidence of its necessity. In
view of the great and increasing difficulty of securing an adequate supply of water
of satisfactory character for very large cities, is it an unpractical fancy that there
may yet come to be provided a double supply through separate pipes : 1st, of
water for drinking and cooking purposes only; and 2d, of water less carefnlly
selected as to source and storage for bathing, washing, house and street cleaning,
extinguishing fires, etc., the former at any rate dispensed through meters to regu-
late consumption ?"

The densely peopled areas of England and the greater probability of
specific infection accompanying the pollution of a water by animal matters
no doubt have led the authorities of that country to look at the danger
rather than at any of the other sides of the water question ; while our, as
yet, different conditions may be considered as authorizing Prof. Mallet, in
certain cases, to give the benefit of the doubt to the water. '

Dr. Klein in his researches into the mutations of micro-organisms has
found reason, while studying the anthrax bacillus, for attaching importance
to the occurrence of spore formation. An altogether new virulence is
developed by the material as a consequence of the formation of spores in
its bacilli ; and this formation has been demonstrated to be largely a. mat-
ter of definable circumstance and condition. Dr. Klein made many suc-
cessive cultures, after the manner which Pasteur and others believe to
produce attenuation of virus, but did not discover any indication of such
a loss of intensity as would allow of the material of a late cultivation
being put into the body of an animal without killing it, or doing it serious
injury, but with the result of thenceforth protecting it against death by
anthrax when the poison of the original disease is inoculated into the animal.

1883.] Transactions of the Obstetrical Society of London. 193

"Thus, Dr. Klein, without throwing doubt on the discovery fry Pasteur of a
material protective against fatal anthrax in the sheep, would guard his reader
against generalizing from Pasteur's experience, and against inferring from it that
an 'attenuated' virus can be had by the recognized method of successive cultiva-
tions in organic liquids at 42° C. There is something more than this wanted for
the production of Pasteur's anthrax ' vaccin,' and the conditions for it have not
transpired from M. Pasteur's laboratory."

Another valuable paper, on the subject of micro-organisms, is that of
Mr. Horsely of University College. This gives an admirable presenta-
tion of the state of our knowledge concerning the septic bacteria. It
summarizes the'principal experimental facts bearing upon the physiological
relations of these vegetable organisms, giving an account of the life-his-
tory of the septic bacteria and of the chemical poison, which appears to
be the result of their vital activity. A copious bibliography is appended,
which will be valued by the student who desires to enter this interesting
field of experimental research. C. S.

Art. XX. — Transactions of the Obstetrical Society of London. Vol.
XXIV., for the year 1882. 8vo. pp. 339. London: Longmans, Green
& Co., 1883.

The volume under review is one of the smallest issued by the society,
and contains but few papers of any length or special interest. As several
of these have been already noticed in this Journal, we shall confine our
remarks to the remainder. The volume is largely composed of short clini-
cal records of cases presented at the meetings, .with or without pathologi-
cal specimens ; comprising those of uterine fibroids, 8 ; ovarian tumours,
o ; diseased or abnormal placentae, 5 ; extra-uterine fcetations, 4; monsters,
2 ; hermaphrodites, 2 ; deformed pelves, 2, etc.

The first paper we shall notice, is that of Prof. W. S. Playfair, on page
84, entitled Notes on 7rachelo-rapLe, or Emmett's Operation. So much
has been written upon this form of uterine restoration and its importance
to female health, by American gynecologists, that it will suffice to give a
few extracts. The operation, although extensively performed in this
country, is new in Great Britain, where it has been received with much
prejudice. Having been admittedly performed in our country in many
instances where it was not imperatively required, the English have gone
to the other extreme, and are many of them inclined to decry the opera-
tion, even in cases in which experience has shown that it is alone capable
of effecting a rapid and permanent cure. As it is now twenty-one years
since Emmet first operated, it seems strange that so little has as yet been
done to test the value of the method in England ; although this has been
accomplished to the satisfaction of several prominent gynecologists on the
continent. Dr. Playfair says : —

" Some eighteen months ago I was in the position in which, T doubt not, many
in this room are at this moment. I was familiar with the writings of Emmet,
Thomas, Goodell, Munde, and others, on traehelo-raph6, but I was very unwilling
to admit that I had been for years misunderstanding my cases, and I looked upon
their statements as exaggerated, and was in fact strongly prejudiced against them.
My attention having been drawn to the subject, I got more and more into the
No. CLXXL— July 1883. 13

194

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[July

way of using a duck-billed speculum and tenacula, and I was soon forced to the
conclusion that the facts at least on which the operation was based were accurate,
and that lacerations did in truth exist with a frequency little less than the Ameri-
can writers stated. So strong, however, were my former views or prejudices,
that I was not induced to try the operation. About this time, a patient who had
been from time to time under my care, sometimes a little better, then bad again,
but never permanently well, went on a visit to America. There she consulted
some one who performed trachelo- raphe, and she came back in a few months
with an apparently virgin cervix, and with all her old symptoms perfectly cured,
and so they have remained ever since. This case was in some sense a revelation
to me, and I determined to put the matter to the test of practice, I accordingly
sent to isew York for the instruments used by Emmet, and I have since per-
formed the operation about twenty times, with the result of satisfying myself that
there is at least a large foundation of fact in the views so ably propounded by
Emmet, and that although the operation may at present be rather overestimated
in America, it is one of great and unquestionable value, which enables us perma-
nently to eure many intractable cases, and which is quite sure ere long to take
a prominent place in scientific practice in this and in every other country."

With regard to the opinion advanced by many gynecologists, that the
existence of a laceration of the cervix tended to give rise to the formation
of epithelioma, a view held particularly by Emmet, Goodell, and Breisky,
Dr. Playfair writes: " "When I was thinking over the matter a good deal,
and before I had ever operated, I saw a patient with my friend Mr. Bex-
ley Thome, who had amongst other local states one of the most distinct
unilateral lacerations I ever saw. 1 pointed this out at the time of our
consultation, remarking that if this patient had been in America she
would certainly have been operated on. 1 heard no more of this case
until May of this year, when 1 was again asked to see the patient, on ac-
count of some recent metrorrhagia, and on examination 1 found the por-
tion of the cervix where the laceration had been situated occupied by a
-mass of epithelioma as large as a turkey's egg. This I excised, cauteriz-
ing the base of the tumour with chloride of zinc, and with a very favour-
able result, there being as yet no appearance whatever of the recurrence
of the disease. In reference to the theory I have mentioned, this case is
certainly curious. Had I seen it with my present knowledge, I would
probably have performed tracl.elo-rapl.e, since the case was one which in
other respects fully justified it, and might thus possibly have saved the
patient a great risk." Dr. Playfair then related some of his cases to showT
the remarkable results of some of the operations performed by him.

The discussion of the paper showed, as its author had stated, the ex-
istence of a great deal of prejudice against the operation ; and evinced an
indifference to give it even the benefit of a trial on the part of some of the
Fellows. Several had tried the operation ; some were pleased with its
results ; others disappointed ; but no one had had the experience with it
t hat Dr. Playfair had Lad as an operator, or valued it so highly as a
surgical expedient. The President of the Society, Dr. J. Matthews Dun-
can, was particularly marked in his opposition, and said that lie was not
impressed in favour of the operation by what he had heard.

On the Natural History of Dysmenorrhea, by Johx WilliamS, M.D.,
is. a paper based upon observations made in 1944 cases; of this number,
874 suffered from primary dysmenorrhea, and 22 from acquired pain, only
11 of which latter were properly cases of dysmenorrhoea, and were due to
fibrous polypus in 1 case; to fibrous tumour in 4 cases ; perimetritis in-
cluding ovaritis in 3 ; movable kidney in 2 ; and hemorrhoids in 1 case.

Of the #74 subjects, 681 were married, of whom 581 bore children and

1883.] Transactions of the Obstetrical Society of London. 195

100 were sterile. In 122 of the fertile women the pain became much less
after child-bearing, and in 177 it was not any better. Of 419 cases in
which the quantity of menstrual fluid was noted, 192 menstruated in very
small quantity. 54 in moderate, and 166 profuse.

The author draws from his observations the following conclusions : —

1. The disease in a few rare cases ceases spontaneously in a few years
after puberty.

2. If the woman continues sterile, marriage generally aggravates the
disorder.

3. Child-bearing cures a large number of cases.

4. The subjects of primary dysmenorrhcea are sterile in the proportion
of one to twelve.

'). Menstruation is regular in about two-thirds of the cases.

6. It is profuse in about two-fifths of the cases, and scanty in about
one-half.

7. The uterus is imperfectly developed.

8. The results of the disorder are slight hypertrophy of the uterus, ero-
sion and eversion of the mucous membrane of the cervix and catarrh.
The uterine cavity rarely measures more than 2^- inches in length.

9. The hypertrophy is attributable to increased muscular action at the
menstrual periods.

10. Ovaritis and perimetritis are possible consequences of dysmenor-
rhoea.

11. Pain results from uterine spasm, excited by the separation and ex-
pulsion of shreds of decidua and clots.

Mr. Hopkins Walters, of Reading, exhibited at the meeting on June
7th, a Uterus torn away by a Midwife, in a Case of Retained Placenta,
with recovery of the patient. As quite a number of recoveries after this
form of malpractice are on record, it will be of interest to note the ana-
tomical character of the parts removed viz: —

tl In front, the separation between the uterus and vagina had been effected at
their line of junction, and the vesico-uterine reflexion of peritoneum was torn
obliquely from the left side, close to the uterine wall, across to the right side, one
and a half inches from its uterine attachment ; and from this portion hung a nar-
row strip of peritoneum five and a half inches in length, which had apparently
formed part of the peritoneal covering of the bladder. Behind, a semicircular
flap of the posterior vaginal wrall. about one and a half inches in length, remained
attached to the uterus. Xear the junction of this with the cervix was a bruise
and partial hiceration, as if a finger had almost penetrated the vaginal wall at
this point. The utero-rectal reflexion of peritoneum was detached along the
uterine wall."

" On the left side of the uterus remained half an inch of the ligament of the
ovary, one inch of the Fallopian tube, and about four inches of the round liga-
ment ; the broad ligament, excepting its extreme upper and lower uterine
attachments, having been left behind with the ovary and the rest of the tube."

"On the right tube, the broad ligament was entire, having been torn from its
pelvic attachments, and contained four and a half inches of the round ligament,
and the Fallopian tube with its fimbriated extremity. The uterus was well con-
tracted and empty, the placenta having been expelled during the manipulations
of the midwife."

" Accompanying the specimen was a piece of omentum about twelve inch.es in
length, that had been prolapsed, and was removed."

The subject of this fearful injury, strange to say, made an excellent
recovery.

Mr. Lawsox Tait reports eighteen operations for Removal of the Ute-

196

Reviews.

rine Appendages, performed by him in the space of seven months, without
a death. The diseases for which he operated were as follows : Double
hydrosalpinx, in 5 cases ; double pyosalpinx, 9 cases ; hydrosalpinx in
right Fallopian tube, and pyosalpinx in the left, 2 cases; and chronic
ovaritis with adhesion of the appendages in the cul-de-sac, 2 cases. In
most of the cases menstruation was profuse, and in two it was hemor-
rhagic. In 14 women, the ages ranged from 28 to 38, and in four, from
43 to 69.

Cases of Transverse Septum in the Vagina Of these, one perforate,

is reported by Henry Gervis, M.D., and one imperforate, by J. Mat-
thews Duncan, M.D., the ages of the women being 22 and 21 years
respectively. In the Gervis case, the vagina appeared to end in a cul-de-
sac at from an inch and a half to two inches from the vulva, and the
menses escaped through a septum, apparently about a line in thickness,
by a small orifice on the left side; In the Duncan case, the septum was
imperforate, and was forced downward against the hymen by an accumu-
lation of menses, forming a convex protrusion in the vulva. In each case
the hymen was annular and well defined. Both were operated upon suc-
cessfully by the thermo-cauter/ ; and in the latter, about three pints of
retained blood escaped, one half immediately, and the balance gradually
during five days. No pressure was made on the abdomen, and no wash
injected per vaginam. The menstrual blood had no fetor at any time. In
the Gervis case, the menstruation was painless; but some retained blood
was found, and the cervix was eroded. The woman applied to be treated
for a persistent and considerable leucorrhoea. Local treatment after the
operation produced a cure of the erosion, and leucorrhoea.

Mr. Alban Doran reports 5 cases of Interstitial or Txbo-uterine Ges-
tation, with Notes on Similar Cases in the Museums of London Hos-
pitals : —

Case 1. Woman 32, mother of two children. Cyst burst at about two
months ; patient lived twelve hours.

Case 2. Cyst of the same character as No. 1. Rupture and death at
two months.

Case 3. Rupture of cyst when foetus measured four inches.
Case 4. Rupture at four months.

Case 5. Rupture at seventh wreek ; woman died from hemorrhage in
twenty-four hours.

" Interstitial pregnancy generally ends in a foetal cataclysm, at the
second or third month," as in cases Nos. 1 and 2. " The tendency to early
rupture of the cyst involves, of necessity, great difficulties in diagnosis."
It is " clearly due to the thinness of the cyst towards its upper or peritoneal
aspect." " I can well understand how the foetus might be born into the
uterine cavity, after expulsion from the sac, and then directly, or after an
interval, delivered from the uterus."

This last opinion is based upon a possible progress of the foetus toward
the nterine cavity ; which is simply a possibility, as the records of cases
show, that the cyst thins in a contrary direction, and the foetus escapes
into the pelvic cavity. The possibility named must remain undecided,
until proved such by autopsy. At present it is, at best, hypothetical.

Dr. J. Matthews Duncan contributes a paper On Puerperal Diabetes.
True diabetes is rarely associated with pregnancy, because the subjects of
it seldom become pregnant, being, in fact, for the time, generally barren ;
but the disease may come on during the pregnant state ; after delivery ; or

1883.] Transactions of the Obstetrical Society of London. 197

during lactation, and gradually advance until it becomes fatal. The
author gives, in illustration, the records of the cases of 15 women, com-
prising 22 pregnancies. One woman very exceptionally became pregnant
three times, while diabetic, miscarried always in the fourth or fifth month,
and died under the last labour. These 15 women varied in age from 21
to 38 years, and were all-, as far as known, multiparas with but one excep-
tion. In several death resulted from collapse. Of the 22 pregnancies in
15 subjects, four ended fatally after parturition. Excessive quantity of
liquor amnii was common, and the fluid was found saccharine in one case.
In 7, of 19 pregnancies, in 14 women, the foetus died after reaching a
viable age, and before labour; and in two more the children were asthenic,
and lived but a few hours after birth. In a tenth case the fostus was dia-
betic.

Dr. Duncan presents the following as his deductions from an examina-
tion of the whole subject : — ■

1. " Diabetes may come on during pregnancy."

2. " Diabetes may occur only during pregnane}', being absent at other times."

3. "Diabetes may cease with the termination of pregnancy, recurring some
time afterward."

4. " Diabetes may come on soon after parturition."

5. " Diabetes may not return in a pregnancy occurring after its cure."

6. " Pregnancy may occur during diabetes."

7. "Pregnancy and parturition may be apparently unaffected in its healthy
progress by diabetes."

8. * ' Pregnancy is very liable to be interrupted in its course :t and probably
always by death of the foetus."

Where the urine of pregnant women in a hospital has been generally
tested for sugar, it is not uncommon to find it in moderate proportion.
This paper of Dr. Duncan opens a new subject for consideration ; and may
lead to the discovery that true diabetes is not' so rare an accompaniment
of pregnancy as has been supposed.

Treatment of Post-partum Hemorrhage by Hypodermic Injection of
Ergotinine, by C. Chahbazain, M.D., of Paris Ergotinine was dis-
covered in Paris, in 1875, by the distinguished chemist, Charles Tauret,
who obtained it in the form of white crystals, insoluble in water, but solu-
ble in alcohol and chloroform. It is believed to be the active principle of
ergot, and exists in very small proportion, one pound of spurred rye yield-
ing but three grains. The dose administered by Dr. Chahbazain was from
^oo *° t^o °f a gr^n? a quantity sufficient generally to excite uterine con-
traction in from three to five minutes.

Twelve cases are reported to demonstrate the efficiency of the remedy
in uterine relaxation and hemorrhage after parturition, in several of which
ergot had previously failed when administered by the mouth. These tests
of the drug were made at the Rotunda Hospital of Dublin, in August and
September, 1882.

Epithelioma, of Cervix Uteri complicating Pregnancy ; Cesarean Sec-
tion ; Recovery of Mother ; Child Living, by Arthur W. Edis, M.D.,
F.R.C.P. — The patient was a 2-para of 29, and was operated upon in the
Middlesex Hospital, on February 26, 1882, after a lapse of 17-J- hours.
The uterus was sutured by introducing interrupted stitches of fishing-gut.
A much larger proportion of patients has recovered in England after the
Cesarean operation for cancer of the uterus than for any other form of
obstruction to delivery. R. P. H.

198

Reviews.

[July

Art. XXI A Treatise on Fractures. By Lewis A. Stimson, B.A.,

M.D., Professor of Surgical Pathology in the Medical Faculty of the
University of the City of New York, Attending Surgeon to the Belle-
vue and Presbyterian Hospitals, New York, etc. 8 vo. pp. 598. Phila-
delphia: Henry C. Lea's Son & Co., 1883.

He is certainly a brave man who writes a new work on " Fractures,"
especially in our own country, where, for nearly a generation, "Hamilton
on Fractures and Dislocations" has been in the hands of almost every
student and general practitioner. Without an apology, explanation, or
statement of " long felt want," Dr. Stimson has given his book to the pro-
fession to be judged upon its merits : to be received or rejected according
as it does or does .not present facts in a clear and comprehensive manner,
enunciate principles correct in themselves and proper to be acted upon,
and advise methods of treatment which will speedily and safely secure the
best results.

More than one-third of the 600 pages of the book are devoted to the
consideration of topics relating to fractures in general, their diagnosis,
modes of repair, methods of treatment, complications, etc. What has been
written is true and well expressed, but, as might naturally be expected, it
is merely a restatement, in somewhat modified form, of what has been over
and again expressed by others in general and special works.

Whenever proper opportunity presents itself the author's full faith in
Listerism is declared, though the use of the spray is considered not
essential to the success of this method ;" Markoe's " through drainage" is
very favourably regarded, as also Guerin's " cotton-dressing ;" of the use
of which, however, in the treatment of fractures, Dr. Stimson states that
he has had no experience.

Respecting the frequently declared predisposition to the occurrence of
fracture produced by syphilis, it is definitely stated that this disease " has
but little, if any, influence ;" and a similar opinion is held of the direct
action of mercury in rendering the bones more liable to break.

Of the use of plaster of Paris it is declared, with great truth, that " it is
blind partisanship that claims for plaster success under all circumstances,
and it is equally blind prejudice that holds it responsible for all compli-
cations that arise under it. Like any other dressing, it must be used
judiciously, and not in a routine manner, and its limitations, as well as
its merits, must be recognized. ... It is well known that early
reduction and perfect retention diminish materially the subsequent inflam-
matory processes ; and, therefore, since the plaster-dressing is, in suitable
cases, the most efficient means of retention, it should be applied at the
earliest possible moment, and as the only danger is that of undue pressure,
watchfulness ought to be a sufficient protection. The interposition of a
thick layer of cotton is an absolute guarantee against this danger, but
diminishes the accuracy of the retention."

Chapters IX. and X., on " vices of union*' as respects degree, kind, and
position, are among the best in the book. Internal remedies for the relief
of delayed union " have not fairly established a claim to confidence," and
when given " with a view to softening the callus and making its rupture
easier, have no effect beyond causing the loss of valuable time ;" the use
of the descending constant current " as a means of stimulating the nutrition
of the limb, and thus promoting the growth and consolidation of the cal-

1883.]

S t i ]\r s o n , Treatise on Fractures.

199

lus," is advised ; if the seton is used, after the method of Physick, its
early removal is recommended, since " an examination of the recorded
cases shows that the dangers are increased, while its efficiency is not, by
the prolonged retention ;" resection, " in cases of real pseudarthrosis and
disease of the fragments the only method that holds out much prospect of
success" may, it is believed, " be stripped of most of its danger by strict
antiseptic precautions." Osteotomy for badly united fracture the author,
though he has never seen it used, feels sure would be " serviceable in cases
of angular or rotatory displacement without such over-riding as would
greatly increase the thickness of the bone at the point where the fracture
would have to be made ;" however, "when a choice can be made, forcible
rupture is to be preferred to division by the saw." This latter statement
certainly admits of an argument."

Of the special fractures, those of the skull are first treated of; it being
held that in these latter days, when, thanks to the antiseptic treatment,
no special danger attaches to a break in a cranial any more than any other
bone, such skull fractures should be looked at simply with reference to the
osseous lesion, and not, as heretofore, to the associated, or likely to be
developed affections of the brain or its coverings. Of the use of the tre-
phine, it is held (and very properly so, we believe) that the mortality fol-
lowing it, " upon which its restriction is so largely based, is to be charged,
not to the operation, but to the lesions whose symptoms finally led to it,
after a delay that had deprived it of most of its chances of success." It is
be hoped that, in the near future, many careful investigations in various
countries will be made to determine, if possible (as Mr. Walsham has
lately attempted to do), the mortality, per se, of this operation, which has
perhaps, more than any other, felt the effects of the pendulum-like vibra-
tion of professional opinion. The bedsores, so likely to form, and that
quickly, after vertebral fractures are thought to be, in the main, due to
pressure, and not to nerve lesion. In two cases of fracture in the lower
dorsal region in adults the author reports having tried the plaster jacket,
44 but without benefit." Of trephining in fractures of the spine, we read : —

" While I believe that the danger of the operation lias been considerably over-
stated by its opponents, and that it might be still further diminished by the use
of the antiseptic method, still, as in many cases, the necessary change in the
position of the parts cannot be effected, because the pressure upon the cord which
it is desired to relieve is made in front by the inaccessible body of the vertebra,
and as the diagnosis must always remain somewhat uncertain and incomplete, I
do not believe surgeons will feel justified in undertaking it except under rare
circumstances, such as fracture in the cervical region with a fair probability of
finding that the pressure upon the cord is due to a displaced spinous process. In
the dorsal and lumbar regions the fracturet even when due to direct violence,
usually involves the body of the vertebra, and if pressure is made upon the cord
inconsequence, it is made in front, and not behind, and its seat is outside the field
of a prudent operation. It is certain that better results have been obtained by
suspension and the plaster jacket, than by trephining, and if the promise held
out by the few cases in which the former method has been tried should be con-
firmed by further experience, there would seem to be no reason to have recourse
to the other."

In the chapter on fractures of the nose, we are pleased to find it stated
that " the interval between the septum and the side of the nose at the
part of the nostril corresponding to the nasal bone is small, so small that
it will not ordinarily admit an instrument as large as a female catheter."
It js certainly high time that the standard direction to lift up the de-
pressed bone with a female catheter was dropped.

200

Reviews.

[July

Fracture of the lower jaw is believed to be located most frequently " at
or near the median line, and single fracture of the ramus or of the alveo-
lar or condyloid process is comparatively rare." This belief is based upon
the results of Gurlt's investigations, which are regarded as more worthy
of acceptance than the estimates of other writers, who " differ much among
themselves, and appear to have spoken in most cases from general impres-
sions rather than from figures.

The commonly received opinion that " in indirect fractures caused by
pressure upon or near the sternal ends of the ribs the bone would yield
near its centre, at its point of greatest curvature," is pronounced u not
supported by clinical or experimental facts. On the contrary, the frac-
ture is found much more frequently in either the anterior or the posterior
third, and indeed the point of greatest frequency seems to be very near
that at which the force is received, an inch or two on the outer side of the
sternal end of the bone." In the treatment of rib-fractures the generally
employed bandage is regarded as 44 seldom more than a comparatively un-
important aid," the patient naturally and instinctively immobilizing the
chest by careful breathing and favourable posture. In the sub-section on
"fracture of the costal cartilages," no notice is taken of the excellent
paper by Bennet, of Dublin (Dub. Med. Jour., March, 1876), in which
he reports six cases of this rare accident, two of them under his care, two
found upon dissection, and two museum specimens. Possibly, had its
author written in French, or lived in New York, the paper might not have
been overlooked.

Of no one of the various methods of treating a fractured clavicle is any
very high opinion entertained, since " the results obtained by the simple
scarf, or sling, are as good as those furnished by the most elaborate
bandaging, and the discomfort to the patient during treatment is much
less. ... If the tendency to displacement is great, the choice of a
method of treatment will depend largely upon the character and wishes of
the patient. If he is indifferent to the deformity or intolerant of restraint,
it is useless to attempt more than a simple dressing; but if he is willing
to submit to the confinement, the fracture may be treated by dorsal de-
cubitus and digital pressure, with a fair prospect of success." The axillary
pad is very justly, as we believe, condemned as either dangerous or useless.

In cases of fracture of the elbow early passive motion is unfavourably
regarded ; " if the joint is not inflamed passive motion is useless, and if it
is inflamed, absolute quiet is what it most needs." Due notice is taken
of Allis's " valuable and interesting paper," the theoretical grounds upon
which his method of treat nient rests, believed to be "entirely sound, and
the practice to be free from objection whenever the extended position does
not favour, as it sometimes does, dislocation of the forearm backward."

The plaster-of-Paris dressing in cases of fracture of the shaft of the
bones of the forearm, is declared to be equally objectionable with the roller
bandage directly applied, " for the same reasons [pressing together of the
fragments and making dangerous constriction] during the first few days,
and is to be avoided afterwards because it prevents inspection of the parts."
None of these objections can lie against the use of plaster palmar and dor-
sal splints held in place by bands or the ordinary roller, and such splints
much more accurately maintain proper apposition of the fragments than
any other.

The low position of the line of break in fractures in the vicinity of the
wrist-joint is duly pointed out ; " the weight of testimony places it at from

1883.]

S tim son, Treatise on Fractures.

201

one-third to three-fourths of an inch above the articular border." The
great majority of these fractures are declared to be produced by ''decom-
position of the force and yielding at the weakest point," the " cross-strain"
theory being regarded as the correct one only in a few exceptional cases.
An attempt is made to prove anatomically that ordinarily the anterior
ligament is not even made tense, " the first carpal row remaining in place
and the second swinging around until it comes almost into contact with
the radius." But the anterior carpal ligament is " connected with both
rows, specially with the second row of the carpus, and with the fibrous
tissue connecting the two rows with one another, i. e., the anterior inter-
carpal ligament ;" and if the second row did possess the power of back-
ward movement independent of the first to the extent claimed, which is
certainly questionable, still the anterior carpal ligament would be made
tense and that in a degree sufficient to exert a powerful dragging force
upon its radial attachment. It is further declared that "the strain does
not come upon the ligament, unless the hand is caught under the body in
the fall and bent far back." Garden has recently reported1 a case in
which the fracture was produced by a violent forcing backwards of the
hand in an attempt at saving a child in the arms from falling, in which
there was no fall, no catching of the hand under the body, nothing but
simple over-extension. Though reference is made to Gordon's mono-
graph, Lecomte's paper, published fifteen years earlier, is not mentioned,
a paper in which the causation " par arrac he men? " was strongly insisted
upon. It is gratifying to find our author declaring that, in these fractures
in the lower end of the radius, " it is often impossible on account of the
crushing, comminution, or impaction, to reduce the displacement com-
pletely, or to maintain the reduction, and that in such cases permanent
deformity of the parts is inevitable." There is at the present day alto-
gether too great a disposition even among medical men to regard deformity
after fracture as evidence of want of skill or lack of care on the part of the
attending surgeon ; and every writer and every teacher should let it be
clearly understood that only in a minority of the cases is the break
recovered from without some deformity and impairment of functional
integrity.

Fractures of the neck of the femur are classified as those " of the small
part of the neck," and those "at the base of the neck," instead of intra-
and extra-capsular. In cases of the first class, though fibrous union is
ordinarily secured, the possibility of bony union is admitted ; and treat-
ment by immobilization is advised, that the connecting band in the former
may be made close, giving a result practically just as good as if the osseous
continuity of the neck had been re-established.

The difficulty of determining oftentimes whether or not the fracture is
entirely within the capsule is recognized, as also the uselessness of such
determination ; and due recognition is made of the fact that at times it is
absolutely impossible at first to tell whether or not there is any fracture.
As respects the question of the intra- or extra-capsular location of the line
of break, it must always be borne in mind that only by actual inspection
can it be determined in any given case what is the inferior attachment
of the capsule posteriorly ; and if this be unknown, as it must of necessity
be during the life of the patient, how perfectly absurd is most of the dis-
cussion that has been and is still being had upon this subject, and of how

1 Edin. Med. Journal, April, 1883.

202

Reviews.

little value has been the presentation of most of the bony specimens from
which the ligaments have long been completely removed. Respecting the
prevention of shortening after fracture of the shaft, the author, while be-
lieving in its possibility and of its occurrence at times, does not believe that
" there is any mrithod of treatment which can be depended upon to secure
it in any given case, for it can never be known in advance whether or not
the patient will be able to support the traction and pressure necessary to
success."

The weight and extension method of treatment with Buck's coaptation
splints and Volkmann's sliding rest is the one habitually employed by the
author; the plaster-of- Paris dressing being regarded with little favour,
since it " does not furnish complete permanent extension, because of the
absence of an upper fixed point of support." It is advised that the
"patients should not be allowed to use the limb, even with crutches,
until the seventieth or seventy-fifth day, notwithstanding apparent firm-
ness of the union, and that splints should be kept for the same length of
time upon patients whose obedience and reasonableness cannot be counted
upon."

Intercondyloid fractures are not believed to be caused by " violence
transmitted through the patella, which acts as a wedge, and splits oh1' the
condyles," but by a penetration and splitting of the lower by the upper
fragment of the primarily produced shaft fracture. Incision or aspiration
of joints in recent articular fractures, ki to empty them of the effused blood
and synovia," is regarded with little favour unless the indication is very
positive, but "on the other hand it is proper to incise the joint, wash it
out, and drain it at the earliest possible moment after suppuration has
begun."

Fractures of the patella, " in the great majority of cases," are believed
to be caused by the contraction of the quadriceps, and the separation of
the fragments is thought to be due in great part to the retraction of that
muscle; ''but not entirely so, for from the moment that the joint becomes
at all distended by an effusion of either blood or synovia into it, the frag-
ments are pressed apart by the liquid to meet the need of more space."
It is certainly often the case that the early muscular action produces very
little separation, the lateral fascial attachments being in part at least
untorn, and if joint inflammation can be prevented or greatly limited by
compression or the application of cold, the fragments will not at any time
during the progress of the case be found removed to any considerable dis-
tance from each other. A light plaster-of-Paris dressing over the limb,
with a large opening over the knee, to the edges of which hooks are fixed
for the attachment of rubber bands to press the fragments together, is the
apparatus preferred in the treatment of these fractures.

The objections to the Malgaigne hook are stated to " seem to be
mainly sentimental, the dislike to penetrating the skin and causing pain."
How sentimental those surgeons must be who agree with Agnew in re-
garding this hook as an " infernal machine 1"

Leg-fractures are classified according as they affect the articular ends
of the tibia, the shaft of that bone, or the fibula. Attention is specially
directed to the exceptionally serious prognosis of tibial fractures when the
break is located very high up, and the unusual length of time required for
the establishment of firm union. " No satisfactory explanation has been
given of this peculiarity." In the treatment of fractures of the shaft
preference is indicated for the early use of the fracture-box with cooling

1883.] SayrEj Orthopedic Surgery and Diseases of the Joints. 203

lotions (e. g., the lead and opium wash), and later the pJaster-of-Paris
immovable dressing; it being thought better u to defer complete encase-
ment in plaster until after the primary swelling has subsided." Many of
such of the readers of this book as have treated a considerable number of
these cases will beg leave to differ. Certainly nothing can be more com-
fortable to the patient and less troublesome to the surgeon, nothing more
likely to secure the desired repair tuto, citoque jucunde than an early and
properly applied " stirrup-dressing," held in place by bands here and there,
or, if preferred, by a roller extending from the toes to the middle of the
thigh. If the fracture was in his own leg, it is very possible that the
author would hardly be willing to lie for ten days on the flat of his back
with the limb in a fracture-box waiting for the subsidence of an inflam-
matory swelling that ten chances to one might have been prevented by an
early application of an immovable dressing, a dressing that by no means
necessitates complete encasement of the limb. The paragraphs on "frac-
tures at the lower end of the leg" present clearly and succinctly the chief
features of these very common and troublesome injuries. Here again
the use of a fracture-box for a week or ten days is advised, and very
properly too, " if there is much swelling, ecchymosis, and tenderness, if
blebs have formed ;" but in a considerable proportion of cases, especially
of those seen early, there will be no such symptoms developed if com-
plete reduction of the displacement is made and fixation of the fragments
secured by immobilization of the leg and foot. Here, as in other joint-
fractures, hours if not minutes are of value, and it is such injuries, per-
haps, that have given rise to, certainly give reason for, the popular idea
that fractures must be set at once. In cases of simple fracture of the
astragalus, with displacement of a fragment, immediate removal of the
latter is thought fully justified (as also of the rest of the bone if neces-
sary) ; and in compound fracture the same course is unhesitatingly advised.
Such procedure is without doubt the proper one in hospital or city practice,
but in more favoured sections of the country where the patient can have the
benefit, not only of careful nursing, but of the best hygienic surroundings,
both part and life can undoubtedly be frequently saved.

The mechanical execution of the work is what might have been ex-
pected, knowing the publishers, and the plates (of which there are three
hundred and sixty) are in unusually large number new and well exe-
cuted. A very few typographical errors, some of them in proper names,
have been noticed, but none of any special importance.

Taken all in all " Stimson on Fractures" is an excellent work, well
deserving of and repaying careful study, and is a real addition to profes-
sional literature. P. S. C.

Art. XXII — Lectures on Orthopedic Surgery and Diseases of the
Joints. By Luwrs A. Sayre, M.D., Professor of Orthopedic and
Clinical Surgery in Bellevue Hospital Medical College, etc. etc.
Second edition, revised, and greatly enlarged, with 324 illustrations.
8vo. pp. xx., 569. New York : D. Appleton & Co., 1883.

In the number of this Journal for July, 1876, we expressed the very
high opinion we entertained of the value of this book, and it gives us

204

Reviews.

[July

pleasure to reiterate that opinion now. It is a book of expedients rather
than of dry pathological details, although this foundation of treatment is
by no means neglected. On turning over its pases there will be found
those practical applications of the healing art which are acquired by ex-
tended experience, and which prove of inestimable value to the general
practitioner.

The work has been very thoroughly revised and the later experience of
the author incorporated in it. The haste with which it was originally
issued led to many carelessnesses of expression, which in this second edition
have been almost entirely removed, to the great literary improvement of
the volume. A large number of new illustrations have been added. Con-
spicuous among these, both by its position as the frontispiece, and the im-
portant teaching it conveys, is the lithograph exhibiting the appearances
presented after an excision of the head of the femur. The operation was
done in September, 1875, upon a child two years and nine months old.
The wound healed almost perfectly, but waxy degeneration of the viscera
ensued, and the child died in March, 1878. Upon examination it was
found "that not only was the bone reproduced very nearly in form and
size, as well as length, of t lie opposite one, but also that true articular car-
tilage had been newly formed, and the motions of the joint were quite
free."

It is in connection with resection of the hip-joint for coxalgia that Dr.
Sayre has achieved some of his notable triumphs, and has attracted de-
served attention. It has been largely through his boldness, and his en-
thusiastic advocacy of it, that this operation has been proved to be com-
paratively free from danger. In a table compiled by his son, Dr. Sayre's
experience with this operation in seventy-two cases is presented to the
reader. In the former edition but fifty-nine cases were tabulated. Out
of the entire number now scheduled, recovery is stated to have followed
in sixty-three cases, while nine died from the exhausting etfects of hip
disease. Forty-seven were alive when this volume was prepared, and a
summary analysis of the results makes a very favourable showing. From
our own experience with, and observation of this operation, we have
learned to regard it as one but rarely fatal, as very generally prolonging
life, but as not ordinarily attended with such satisfactory ultimate results
as Dr. Sayre has recorded in this volume.

Since the publication of the first edition of these lectures, the method
of treating spinal curvatures by extension, and a fixed jacket, then a novel
procedure, has been largely developed by Dr. Sayre, and brought fully
before the profession by other publications and repeated demonstrations.
The favourable opinion of the method we expressed when Ave first re-
viewed this book, has been abundantly borne out by the experience of the
profession since. The trial which we then proposed to give the proceed-
ing has been repeatedly made since, and always with satisfaction. The
principle underlying the treatment originated by Dr. Sayre is the correct
one, and the profession and very many of the laity are indebted to him to
a degree which can hardly be exaggerated. Some surgeons prefer to use
other material for the construction of the jacket, merely using it to obtain
an accurate cast of the extended body, upon which a leather, poro-plastic,
or other jacket can be fitted, but the principle is the one with which the
profession has become acquainted through the enthusiastic efforts of Dr.
Sayre. For ourselves we have been abundantly satisfied with the plaster
jacket. Objection has been made that it is dirty, but we have found that

1883.] Sayre, Orthopedic Surgery and Diseases of the Joints. 20-5

with reasonable care tolerable cleanliness can be preserved. Then the
application is so easy, and the material so cheap, that the renewal of the
plaster corset provides a ready remedy. We have known one to remain
on for six months, and though this is an extreme length of time and cer-
tainly greater than is desirable, it goes to show that when properly applied,
and properly attended to afterwards, it provides as nearly permanent a
form of dressing as we can well hope to obtain. Especially is this
the case in growing children. Of course some other substance may
be found to answer, and as we have said, there are several such in
constant use which give satisfaction ; but inasmuch as the plaster
roller can be applied by any careful physician, without recourse to the aid
of instrument-makers, and gives good results, extending over a considera-
ble course of time at a very moderate cost, we are of the opinion that the
plaster jacket is entitled to a long lease of life. Yet in this day of inven-
tions it is quite possible some other, cleaner, and equally reliable sub-
stance may be found to be a desirable substitute for it, but we feel quite
sure that the principles of treatment will remain unchanged.

The method of applying extension to the cervical portion of the spinal
column, by what Dr. Sayre calls his jury-mast, we have also repeatedly
tested, and with marked advantage in suitable cases.

Dr. Sayre is careful to point out that while he uses a plaster corset
in lateral curvature of the spine, it is only as an adjuvant to careful gym-
nastic exercise of the muscles. He only allows it to be worn during the
daytime, as a comfort and aid to the weakened muscles. As the aid of
the instrument-maker is required to complete this corset, the leather jacket
seems to us to possess advantages in this class of cases.

The book has been considerably enlarged, the number of lectures hav-
ing grown from twenty-nine to thirty-one, and, as before said, many new
illustrations have been added. The index is also enlarged and improved.
Indeed, the whole volume is an advance upon the first edition, both in
style and material. It brings the subjects treated of in it up to the pres-
ent time, and gives its author's latest and matured views. Records of
personal experience, when honestly and fairly told, are always valuable, and
as such this book is an important one. Of course Dr. Sayre is well known
to be an enthusiastic man, and many will refuse to see things exactly as
they appear to him, but it is the enthusiast who impresses those with
whom he comes in contact, and to Dr. Sayre's enthusiasm the profession
owes much.

Few books have the personality of their authors more forcibly impressed
upon them than this one. This fact gives piquancy and interest to the
volume, and the reader of it will rise from its perusal with the impression
that its author has written of that he has had experience in, and that the
extent of Dr. Sayre's experience gives weight to his opinions. Although
not yet the complete treatise we have expected to see from the pen of the
Belle vue Professor, and which we yet hope to see produced by him, the
present volume is a step in that direction. Meantime every surgeon who
has to do with the subjects of which it treats will do wisely to have this
volume within easy reach upon his shelves. S, A.

20G

Reviews.

Art. XXIII A Manual of Practical Hygiene. By Edmund A.

Parkes, M.I)., F.R.S., late Professor of Military Hygiene in the Army
Medical School, Member of the General Council of Medical Education,
Fellow of the Senate of the University of London, Emeritus Professor of
Clinical Medicine in University College, London. Edited by F. S. B.
Francois De Chaumont, M.D., F.R.S., Fellow of the Royal College
of Surgeons of Edinburgh, Fellow and Chairman of Council of the
Sanitary Institute of Great Britain, Professor of Military Hygiene in
the Army Medical School. Sixtli edition. 8vo. pp. xix. 731. Phila-
delphia, Pa.: P. Blakiston, Son & Co., 1883.

We looked for the new edition of Parkes's Hygiene with an interest
which was probably shared by a majority of the profession in this country
as in England. Sanitary science is popular, and the general practitioner
must keep himself well informed as to its precepts. His position as ad-
viser necessitates a thorough knowledge of the more important sanitary
questions, and an occasional reference to some standard volume for light
on points which may be obscure or ill-defined. There are few of us,
therefore, without some work on hygiene on the book-shelf, and that work
is usually Dr. Parkes's Manual, which appeared about twenty years ago
as a text-book for the young military surgeon. Although prepared for a
special class of readers, it filled a vacant space in the medical literature of
the English speaking people; and medical men in civil life studied it for its
principles and applied its teachings. In the fourth edition, published in
18J73, its scope was enlarged, and it was put in better form for its civilian
readers ; the discussion of questions of a chiefly military character being
transferred in this revision to a second part. A fifth edition appeared in
1878, but in the mean time the author, who had given such an impetus to
practical sanitary work, died, and the issue was made by Dr. De Chau-
mont, his successor in the chair of Military Hygiene in the Army Medical
School.

The sixtli edition, now before us, is also edited by Dr. De Chaumont,
who, in a short preface, indicates the character of his work, by stating that
he has omitted matter which had either become out of date or was no
longer necessary, by which space has been obtained, without material in-
crease of the volume, for matter which the progress of science and the
results of experience rendered it advisable to add. 'k Some slight changes
have been made, such as putting all the directions for making chemical
solutions in one appendix at the end, and uniting all the questions of dis-
infection and deodorization in one chapter." We take no exception to
these changes ; but there is a change unmentioned in the preface which
we think Dr. De Chaumont ought not to have made. The personality of
Dr. Parkes has been thoroughly eradicated from the volume. The per-
sonal pronoun which he occasionally used in the text, and more frequently
in the foot-notes, and which placed one so much in sympathy with the
author, is eliminated, and either the editorial plural takes its place, or the
sentence is remodelled to exclude the pronoun ; in the foot-notes, however,
the first person singular remains of frequent occurrence, but it is the
editor, not Dr. Parkes, who speaks. Few will consider that Dr. De
Chaumont's labours have so appreciated the text as to warrant this liberty
with the personality of his author.

Many of the notes of former editions have disappeared by embodiment

1883.]

Parkes, Manual of Practical Hygiene.

207

in the text.. The omissions are few. Two only are noteworthy, and we
regret them both. Dr. Parkes, in speaking; of the exhausting effects of
heat, calls attention to the fact that there is then really lessened quantity
of oxygen in a given cubic space; and to give a definite value to tins
diminution, he added in a note a calculation to show that in the 16.6 cubic
feet of air that a man draws into his lungs in an hour, there would be, at
80° Fahr., 192.6 grains of oxygen less than if the air breathed was at
32° Fahr. The experience of the teacher dictated this note, which is
omitted in the present edition. The other involves the tables of watery
vapour in air at different temperatures and the relative humidity from wet
and dry bulb observations. The new volume refers us to Glaisher's tables,
but the sections of these tables originally printed by Dr. Parkes, were
sufficient for the needs of the sanitary student, and rendered such a refer-
ence unnecessary.

On opening the volume for perusal, we found on pages 2 and 3 refer-
ences to Buck's Hygiene which were flattering to our national esteem,
inasmuch as from this early appearance of American work in the new
edition we anticipated many future acknowledgments of the ability and
perseverance of our sanitary men. "We were disappointed in finding that
the observed references related only to a statement of the water supply per
head in American cities. But our disappointment was greater on disco-
vering that, although Buck's Hygiene was in the hands of our editor, he
finished his revision without having again occasion to refer to its pages.

Dr. De Chaumont lias paid much personal attention to the work of the
water analyst, and, as might be expected, there are some additions to and
changes in the text on this subject. Indeed, more labour has apparently
been expended on the revision of the long chapter on water than on any
other part of the volume, yet those who have studied this subject will be
disappointed with the result. The 16 influences ," as the careless proof-
reader has it, deducible from the quantitative tests are stated at greater
length than in the old edition, but their character remains unaltered. No
notice is taken of Dr. Cory's experiments on intentionally polluted waters,
published in the Supplement to the Eleventh Annual Report of the Local
Government Board, nor of the similar but more extended investigation
carried on by Professor Mallet, of the University of Virginia, an ab-
stracted report of which appeared as a Supplement to the Bulletin of our
National Board of Health. Hence no discussion of the results, as influ-
encing the " inferences" is presented. The possible presence of bacteria
of a specially poisonous character in water is admitted, and a reference is
made to the fermentative nature of the nitrification process ; but the sen-
tences are meagre and unsatisfying.

Indeed, the changes in this edition are so few that we feel at liberty to
note them seriatim tor the benefit of those who have not the volume at
hand. In speaking of the 7-elative sanitary advantages of the intermittent
and constant systems of water supply a distinct preference is given to the
latter, although no new facts are introduced as the basis of the preference.
A paragraph appears showing, on the authority of Mr. G. Deacon, that
the loss on the constant system occurs from leaks in pipes and drawn joints
before the water reaches the consumer. It is considered unadvisable to
use charcoal for filtration on the large scale, chiefly because low forms of
animal life are prone to develop in the water. Spongy iron does not so
affect the water, and, as it retains its filtering power for "a very much
longer time" than animal charcoal, it should be used in preference, al-

208

Reviews.

[July

though filtration through it takes place more slowly than through charcoal.
Carferal, the composition of which has not been made known, but which
is understood to consist of carbon, ferrum, and a/umina, is considered
better than charcoal, but less valuable than the spongy iron. In speaking
of malarious waters a paragraph is given to experiments by Dr. Smart,
U. S. Army, published in this Journal, January, 1878, showing the coin-
cidence between malarial fevers and impurity, derived from rain falls and
snow meltings, in the water supply. The malarial poison is blown up
with vegetable organic matter from the plains, precipitated with the
rain or snow, and, when the latter melts, is carried into the streams.
Should the views of Klebs and Tomassi-Crudeli be confirmed, the exist-
ence of malaria in water must be looked upon as still more probable. The
well-known Caterham epidemic is added to the list of cases of typhoid
propagation by the water supply, but no notice is taken of the singular
case at Lausen, although the latter demonstrated the passage of the fever
poison through a natural soil-filter which removed the minute granules of
wheat starch. The probability of the transmission of the poisons of scarlet
fever and diphtheria by water carriage, either directly or by their being
mixed with milk, is allowed. Some additions are made to the instructions
given concerning the collection of water for analysis. Chlorine is deter-
mined, as in the older editions, by silver solution and potassium chromate.
The difficulty of obtaining exact results by this process in the presence of
much organic matter is not recognized, nor is there a notice of Sal-
kowski's method of determining the chlorine. De Chaumont's own pro-
cess for the estimation of nitrous acid, by the use of permanganate before
and after the destruction of the acid, gives place in the new edition to
Greiss's process with metaphenylenediamine, which is said to be now ac-
cepted as the most accurate method. Our editor does not appear to have
heard of the use of naphthylamine hydrochlorate and sulphanylic acid,
which possess the advantages of being even more, delicate and of giving
a coloration which is not liable to be simulated by organic or other mat-
ters in the water.

In the chapters on air, the first addition encountered is a paragraph
giving the results of Fodor's experiments on the carbon dioxide, which
extends the limits of that gas, in what may be considered as normal air,
to G vols, in 10,000. In the section treating of the living substances in
air, to which diseases are attributed, two short paragraphs have been in-
troduced, by which we learn that Pettenkofer, Von Nageli, Fodor, and
others distinctly attribute specific diseases to bacilli of certain kinds, that
the connection of wool-sorters' disease with a bacillus probably inhaled
from the atmosphere has been established, and that Koch has recently
demonstrated the existence of a bacillus in phthisis, and has apparently
succeeded in cultivating it and propagating the disease by that means.
In view of these investigations, and those of Klebs and Pasteur, the sen-
tence on page 511 of the fifth edition, " yet it is certain that, in some ot
the epidemic diseases, there are no bacteria," has been altered to: "yet
in some of the epidemic diseases no bacteria have been as yet demon-
strated."

In treating of the connection between sewer air and typhoid fever a
new paragraph appears, inviting attention to the German opinion that
sewer air can have no causative influence, because it is rare that such air
gets into houses, with references to the papers of Soyka, Renke, A. de
Rosahegyi, and Lissauer. There are some alterations in the section treat-

1883.]

Parke s, Manual of Practical Hygiene.

209

ing of the amount of air required, and it is proposed for agreement that
the quantity needful for adult males in repose be accepted as 100 cubic
metres per hour, or about 1 cubic foot per second. Marker's experiments
on the amount for animals are referred to and figures are given, but the
whole may be summarized in the closing sentence, that cattle "ought to
be practically in the open air." In the article on ventilation a new sec-
tion appears, discussing losses by friction. This informs us that the loss
by this cause in tubes of equal diameter is directly as the length, and in
those of equal length it is inversely as the diameters ; that each right
angle diminishes the current by one-half, and that circular tubes are best
because they include the greatest space within their periphery. The only
other change in the chapters on air is the condemnation of cowls, as hav-
ing been shown by the labours of the Sanitary Institute of Great Britain,
to have no superiority over the open tube.

The chapters on food are unaltered except by the statements that
ground date-stones have been mixed with coffee, and glycerin met with
as an adulterant of milk, and by the introduction of a few lines on the
alteration of the specific gravity of the latter article by watering and
creaming.

But for a paragraph suggesting the importance of the microscopic ex-
amination of soils, in view of recent observations on bacteria and nitrifica-
tion, the chapter on soils is unchanged.

In the discussion of the efficiency of traps, forming part of the chapter
on the removal of exereta, we find the results of the experiments of
Messrs. Philbrick and Bowditch embodied in the text, showing the danger
of " unsiphoning, which small pipes are exposed to." " The experiments
also showed how unsiphoning might take place from the pressure descend-
ing water from upper floors, so that air might be forcibly driven into the
house when upper closets or sinks were used." Dr. De Chaumont does
not appear to have understood this American paper, or has failed to ex-
press himself with the clearness whieh we require in a text-book. Traps
in small pipes are liable not to unsiphoning, but to the loss of their seals by
siphonage. The experiments also showed how the siphoning or unsealing
of traps on branch fixtures might be effected by a rush of water through the
main soil pipe as from a closet on an upper floor. Water coming from an
upper closet will drive the air in the soil pipe before it, producing condensa-
tion by a piston-like action, and, if there is no foot ventilation or fresh inlet
to the soil pipe, the condensed air may force the traps in branch fixtures,
thus permitting a puff of soil-pipe air to enter the rooms. But when the
water in the soil pipe has passed, the air behind it has a diminished ten-
sion, and the pressure ot the external air on the seals of branch traps may
force the trap waters over the upper bend of the pipes, and lead to their
discharge by siphon action.

The charcoal trays, described in the old edition as used in the man-
holes and ventilators of sewers, are disposed of in one sentence in the new
volume : " The use of charcoal trays has not answered the expectations
that were formed of them." Two other short sentences comprise all the
new matter on sewerage. They relate to Shone's ejector system. ft This
is an opposite plan to Liernur's, the agent being compressed air instead of
exhaustion. It has been applied at Wrexham and at Eastbourne, and is
well spoken of." No alteration has been made in the article on the
separate system of sewerage, although we have had an extensive experi-
ment in Memphis, Tenn., which seems worthy of note in a book of this
No. CLXXI July 1883. 14

210 Reviews. [July

kind. In the examination of house pipes and traps we find no mention of
the popular peppermint test ; nor is anything said of the fresh-air inlet for
the through ventilation of the house pipe, which has been so much dis-
cussed recently by sanitary engineers.

On the section on the barometer a rule is given, as by Mr. R. Strahan,
for the approximative determination of heights : —

" Read the aneroid to the nearest hundredth of an inch; subtract the upper
reading from the lower, leaving out or neglecting the decimal point; multiply
the difference by 9 ; the product is the elevation in feet. If the barometer at
the upper station is below 26 inches, or the temperature above 70° Fahr., the
multiplier should be 10."

In Book II., on the service of the soldier, some changes appear, owing
to the incorporation of the army statistics of the past few years. The
•short article on Cyprus, occupied in 1878, is new. Some changes are also
noted in the clothing of the soldier, the chief of which is the abolition of
the old leather stock.

In connection with the " influences" noticed above, it may be stated
that, on page 196, the misquotation of the old edition is permitted to
stand. Speaking of inorganic substances, Dr. Pavy said that they " are
hardly of sufficient importance, in an alimentary point of view, to call for
their consideration under a distinct head." The sense is not improved
by the careless substitution of so-called for to call. A text-book should
be free from blemishes of this kind. C. S.

Art. XXIV Health Reports.

1. First Annual Report of the Provincial Board o f Health of Ontario,
being for the year 1882. Toronto, 1883, pp. 223.

2. Fifth Annual Report of the Connecticut State Board of Health for
1882, with Registration Report for 1881. Hartford, 1883, pp. 445.

•3. Sixth Annual Report of the State Board of Health of New Jersey,

1882. Woodbury, X. j., pp. 361.
4. Tenth Annual Report of the Secretary of the State Board of Health

of Michigan, for 1882. Lansing, 1883, pp. 630.

1. The report from Ontario to be first welcomed as another encourag-
ing proof of awakening public opinion in regard to its most important
interest, the care of public health, opens with an account of the organi-
sation of the board and a general history of its work, which for that of a
year old baby is creditable in the highest degree.

The establishing act provides that the " Provincial Board of Health of
Ontario" shall consist of not more than seven members (appointed by the
Lieutenant-Governor in council), at least four of whom shall be duly regis-
tered medical practitioners. These members serve without pay, except the
chairman, who receives $400, and the secretary, who receives $1000, but
their travelling and other necessary expenses are allowed.

Efforts were very wisely made to utilize the experience of other similar
organizations to the best advantage, by sending representatives to attend
various sanitary conferences, such as the International Congress of Hy-

1883.]

Health Reports.

211

giene, at Geneva, in Switzerland, and the Convention at Greeneville, Michi-
gan, held under the auspices of the energetic Michigan Board of Health ;
also to study the methods of work found most practicable by the Health
Boards of Massachusetts, New York, Detroit, Toledo, etc., and the infor-
mation thus gained appears to have been judiciously adapted to the needs
of Canadian climate and modes of life. Obviously the duties of a board
of health for some time after it is first originated, are chiefly to dissemi-
nate hygienic knowledge, and to accumulate statistical information, etc.,
rather than to attempt original researches into the causes of disease, which
will contribute to the common stock of knowledge possessed by the sanita-
rians of the world. Accordingly we find that an important part of the
work of this Board during the first year of its existence has been the dis-
tribution of well-written pamphlets on the means of checking the spread
of contagious diseases, or resuscitation of the apparently drowned and
kindred subjects. Reports of commissions to investigate endemics of
typhoid fever and malaria in various parts of the province possess an emi-
nent local value, as do those in regard to an immigrant inspection service,
respecting the records of diseases, and the specimen of the " Weekly
Health Bulletin" with accompanying explanations.

About thirty pages in the latter part of the volume are occupied with
an account of a sanitary convention held at St. Thomas, in imitation of
those so successfully organized in various parts of Michigan. At this
conference several "local gentlemen" read papers upon such timely topics
as the advantages of sanitary education, the adulteration of foods, the
ventilation of school-rooms, etc.

Finally, we are favoured with a synopsis of two popular lectures on
sanitary subjects, delivered by Dr. P. H. Bryce, Secretary of the Board,
in the autumn of 1882. The first of these discourses is 4; Upon Typhoid
and some other Zymotic Diseases, and their Causes and Prevention ; the
second on " School Sanitation ; its Necessity and Methods." Without
containing any thing new of great moment, these lectures are filled with
old and well-tried truths set forth in as clear or even eloquent manner,
and indicate that their author is an accomplished sanitarian, who has kept
pace with the hygienic literature of the day, thus qualifying himself for
the responsible position he has been called upon to fill.

2. The Connecticut State Board of Health Report comes to us in an
enlarged and improved form, affording another evidence of the advancing
appreciation of the claims of public hygiene upon popular attention. The
able secretary of the board devotes several pages to a congratulatory re-
view of the proofs of encouraging progress in this direction, among which
he justly classes the important action of the Illinois and West Virginia
State Boards of Health, in controlling medical practice, and elevating the
standard of medical education, which he duly praises as " a work of ines-
timable value."

Dr. Chamberlin informs us that although smallpox occurred in a num-
ber of places in the State during the year, there has been no general or
even partial epidemic, an immunity which he attributes partly to the sup-
posed inactivity of the contagion before the fifth day of the eruption, but
more especially to the good management of the cases when they first ap-
peared, and the prompt employment of vaccination. The subject of alter-
nate epidemic waves of malaria and typhoid poison is discussed at some
length, and whilst admitting that our facts as yet are too few for any com-
plete generalization upon this obscure question, Dr. Chamberlin contends

212

Reviews.

[July

that observations in New England show that there is no complete law of
exclusion in the two types of disease. Scarlatina is stated to have been
more than usually prevalent, especially during the winter of 1881-2, and
precautions against its continuance, in view of the probability that its
peculiar poison may reproduce itself outside of the human body, and espe-
cially in the bloody washings of slaughter-houses, are very judiciously in-
sisted upon.

Among the important papers on special subjects may be mentioned that
of Dr. L. Dennis on " Hatting as affecting the Health of Operatives,"
which is reprinted from the Third Report of the New Jersey State Board
of Health, because the occupation is extensively carried on in Connecticut,
and many of the facts upon which the essay is based were derived from
observations made in that State. It calls attention especially to the dan-
gers to hatters of mercurial poisoning, which occurred in 108 out of 1546
operatives in hat factories, 107 of these sufferers being found among the
438 "black finishers." Prof. William H. Brewer contributes a syllabus
of his well-arranged lectures on Sanitary Science, in the Sheffield Scien-
tific School, which it is suggested might serve to outline a course of in-
struction in hygiene that would replace with great advantage some of the
less practical branches, so elaborately taught in colleges and the higher
class of schools. An interesting article on " Epidemic Intermittent Fever
and its Annual Progress in Connecticut and other parts of New England,"
furnished by G. H. Wilson, M.D., of Meriden, is illustrated by an exten-
sive map; and besides attending to his arduous duties, the industrious sec-
retary, Dr. Chamberlin, has contrived to find time for preparing valuable
papers on " Milk as a Medium for the Transmission of Disease," "On
Impure Ice," and " On some of the Organic Impurities found in Drinking
Water," the last of these being illusi rated by several wood-cuts and two
photo-lithographic plates. Another important illustrated article is that of
Noah Cressy, M.D., V.S., on "Protective Inoculation," in which are
reviewed the wonderful results of Pasteur's late experiments upon the
" attenuation" of the splenic fever virus, and the brilliant light they throw
upon the relations of vaccina to variola, as well as the emphasis they give
to the necessity of the strictest sanitary precautions, such as disinfection
and isolation, which is clearly pointed out.

The volume concludes with the Registration Report for 1881, the tables
of which, with their explanatory text, occupy 128 pages.

3. The New Jersey Report opens with that of the eminent Secretary,
Dr. Ezra M. Hunt, of Trenton, in which he likewises expresses the con-
viction that the popular mind is more fully than ever before taking the
higher and well-sustained view that health administration on the part of
the State is no longer to be looked upon only as a charity, and that " race
vitality, physical vigour, and the avoidance of the ascertained causes and
concomitants of disease are essential to the welfare of the people and to
the prosperity of the body politic." Dr. Hunt informs us that the births
during the year were 23,108, whilst the deaths numbered 25,942, an ex-
cess of more than 12 per cent., some of this excessive mortality being, he
considers, due to the exceptional winters and summers of the years
1879-81. Local outbursts of diphtheria occurred in several places.
Measles was largely epidemic in the State, but not in a fatal form. A
somewhat diffused prevalence of scarlatina existed, and smallpox appeared
in many localities, whence it would doubtless have become generally epi-
demic had it not been for the efficiency of local health boards, supported

1883.]

Health Reports.

213

by more intelligent popular views in regard to early isolation and vaccina-
tion. A praiseworthy attempt at securing that great desideratum, a pure
water supply, has been made by the appointment of a State commission
upon this subject, and the able secretary's sound and pertinent remarks
upon drainage, sewers, offensive trades, contagious diseases of animals,
vaccination, etc., are well calculated to perform valuable service in pre-
serving the health of his fellow citizens.

An essay on the " Disposal of Sewage in Cities," by Julius W. Adams,
C. E., professes to be only a review of the several systems which have
been proposed, and especially urges that, 1st. Fresh-water streams can
undoubtedly destroy organic impurities which are mixed with them. 2d.
The depurative capacity of any particular streams depends on the degree
of dilution of the foul matters, the amount of disturbance of the current,
season, climate, presence of aquatic plants, and the time of exposure of
the sewage to these agencies. 3d. That although far more extended in-
vestigations are necessary, the few facts already in our possession enable
us to partly calculate the expediency of using any particular water-course
as a receptacle for sewage.

A short paper on the " Regulation of Moisture in Rooms," by Prof. C.
F. Brackett, gives some obscure hints upon this rather abstruse subject,
and the secretary's report of " Local Sanitary Inspections of Sea-side
Resorts," etc., afford important data for the consideration of seekers after
health and pleasure at the various watering places on the Atlantic coast
of New Jersey. One of the most valuable articles in the volume and one
which represents a vast amount of diligent investigation, is that of Prof.
Albert R. Leeds, upon u Health Foods, Invalid Foods, and Infant Foods."
We regret that want of space prevents us from noticing more than our
author's conclusions upon this important subject, these being, that of the
first class, the farinaceous foods, since by no process of cooking or baking
at present known can the larger part of the amylaceous matter be con-
verted into sugar or dextrine, none are well adapted for the nourishment
of young infants. The Liebig foods, which form the second class, are
deficient in carbohydrates,, whilst the third class, the milk foods, also ex-
hibit too great a proportion of saccharine matters to the albuminoids, so
that " whilst the market supplies us many more or less excellent infant
foods, one not open to these objections, and entirely satisfactory, has yet
to be made." A brief report of Dr. William K. Newton, Milk Inspector,
a reprint of the admirable circulars and laws issued by .the Board during
1882, and the report of the Bureau of Vital Statistics, conclude this im-
portant addition to the series emanating from the New Jersey wState
Board of Health.

4. The Michigan Report is as usual a rich treasury of hygienic infor-
mation evidencing anew the eminent ability of its author. Indeed, the
whole organization and management of the Michigan Board of Health
render it a model in this respect to every State in our Union, and enable
it to produce annually an amount of timely, energetic, and efficient sani-
tary work, whereof each member, and especially the indefatigable secre-
tary, Dr. Henry B. Baker, may well be proud.

We learn from the secretary's report on the communicable diseases, that
in the year ending September 30, 1882, diphtheria was the malady of
this class most to be dreaded in Michigan, but that it seems plain that
this fatal disease can be quickly suppressed if met by prompt and intelli-
gent action of the health authorities properly sustained by the cooperation

214

Reviews.

of intelligent citizens. Scarlet fever was not nearly so prevalent as it was
in the early part of the last decade, and in 22 out of the 82 localities in
which it was stated to have appeared, the authorities succeeded in restrict-
ing it to a single case. More than 100 outbreaks of smallpox occurred in
some 61 localities, with a total of over 600 cases and about 175 deaths.
In 16 different places the vigilant care of health officers prevented any
spread of the disease, and of the 25 different outbreaks in Detroit almost
every one was confined to the first case.

Of the fifty-seven papers, addresses, and reports comprised in the body
of the work, eighteen were presented at the Sanitary Convention at Ann
Arbor, February 28 and March 1, 1882; twenty-two to the Convention
at Greenville, April 11-12, 1882; and the remainder were chiefly fur-
nished by members and from the office of the board. Among the more im-
portant of these documents we notice the Introductory Address at the Ann
Arbor Convention by President Hon. LeRoy Parker, in which the speaker
took issue with Herbert Spencer in regard to his denunciation of sanitary
laws, and claimed that the State could well afford to spend ten times
what it now does for public service, if half the present annual loss from
preventable disease were saved thereby. Dr. O. W. Wight, Health
Officer of Detroit, gives a thoughtful and well-written paper on " How to
Combat Smallpox," and Prof. Henry F. Lyster, M.D., urgently advocates
a system of tents in his brief essay, entitled ''The Ambulance Hospital
for Smallpox." Jn a short paper on "The Purification of Water by
Freezing," Dr. C. P. Pengra, of Ovid, gives an interesting account of a
few experiments which tend to show that water may part with from twenty
to fifty per cent, of its contaminations during the process of congelation.
Pev. Dr. George Duffield, of Lansing, in a sanitary sermon on " Hygiene
and the Clerical Profession," gives an eloquent account of his own expe-
rience in avoiding some common and everywhere imminent clangers to
health, and sets a bright example to his brother clergymen, which we
hope will induce many of them to enlist with physicians in their warfare
against preventable death. In his paper on " Food Adulterations," Dr.
A. B. Prescott, of Ann Arbor, makes a strong plea in favour of purer
articles of diet, calling attention to the stupendous frauds now being prac-
tised upon the American people by the manufacturers of glucose and oleo-
margarine. Glucose, he tells us, could be sold at the factories at from 1^
to 2 cents per pound, and is really sold for 3 or 4 cents. In the retail
market it brings as good prices as cane sugars ; but of the 300 millions of
tons bought by consumers annually in this country none is vended under
its true name, so far as could be ascertained. Dr. Wm. Oldwright, of
the Toronto School of Medicine, and one of the visiting committee from
the Ontario Board of Health, in his address on the "Exclusion of Sewer
Gas from Houses," made some pertinent remarks upon this subject, which
is now attracting so much attention from sanitarians everywhere, and
pointed out the importance of ventilating all traps. Dr. J. H. Kellogg,
of Battle Creek, contributes an excellent paper on " Decomposing Animal
Matter," illustrated by several wood-cuts, and well calculated to do good
service in awakening public attention to the dangers of neglecting that
cleanliness which we have the highest authority for believing is akin to
godliness, besides being the surest preventive of disease.

Altogether this volume is of a high order of merit, and one which needs
no recommendation from us to render it sought for as a valuable acquisi-
tion to the library of every student of sanitary science. J. G. R.

1883.] The Dispensatory of the United States of America. 215

Art. XXV The Dispensatory of the United States of America. By

Dr. Geo. B. Wood and Dr. Franklin Bache. Fifteenth Edition.
Rearranged, thoroughly Revised, and largely Rewritten. With Illus-
trations. By H. C. Wood, M.D., Member of the National Academy
of Science, Professor "of Materia Medica and Therapeutics, and of Dis-
eases of the Nervous System, in the University of Pennsylvania ;
Joseph P. Remington, Ph.G., Professor of the Theory and Prac-
tice of Pharmacy in the Philadelphia College of Pharmacy, First Vice-
Chairman of the Committee of Revision and Publication of the Pharma-
copoeia of the United States of America ; and Samuel P. Sadtler,
Ph.D.. F.C.S., Professor of Chemistry in the Philadelphia College of
Pharmacy, and of General and Organic Chemistry in the University
of Pennsylvania. Octavo, pp. 1928. Philadelphia: J. B. Lippincott
& Co., 1883.

In its very remarkable career the Dispensatory of the United States
has been associated with that of the Pharmacopoeia during a half century.
The Pharmacopoeia of the United States first appeared December, 1820,
and the first decennial revision of it in April, 1831. In spite of the
earnest desire of the physicians who participated in its formation and re-
vision to establish it. the work was not then generally accepted as the
national authority in the premises either by physicians or apothecaries.
The London Dispensatory by Anthony Todd Thomson, M.D.; The Ed-
inburgh Xew Dispensatory by Andrew Duncan, M.D.,and The American
Dispensatory by John Redman Cox, M.D., were prominent competitors
with others for the confidence of the medical public. Each had followers.
The effort to secure uniformity of composition and of strength of officinal
preparations throughout the country through .the creation of a Pharma-
copoeia of the United States, to be the common and only authority was
then not yet successful. Though the committees to which the publication
was confided were careful to secure the sale of the volume at a minimum
cost, in order that it might be within easy reach of all for whom it was
designed to be the guide, the book was not as largely purchased as its
friends desired. The authors did not expect to be paid for their labour.
A copyright was held, not for profit, but for the sake of having control of
the text and preserving its authoritative quality and form. The object
was to have the authority of the Pharmacopoeia everywhere recognized
and faithfully observed, and whether this should be attained by the use of
the book itself, or from reprints of parts or of the whole of it, did not con-
cern its authors or compilers. They felt no interest in the publisher's
account of sales. Their main object was recognition of it as the working
standard of all apothecaries in the land. There was no legal power to
enforce its observance. Only the force of public opinion could bring it
into use. They designed that the benefits of their enterprise should enure
to no privileged or known class, but be free and common to all. Their
work has all the characteristics of purely public charity, bringing no
emolument to the workmen, and leaving its benefit open to the indefinite
public.

The authors of the Dispensatory had actively assisted in the first decen-
nial revision of the Pharmacopoeia, 1830, and were familiar with the aim
and policy of those who participated in its creation. In Europe the Na-
tional Pharmacopoeias are prepared under governmental authority, and

216

R E V 1 E AV S .

[July

their observance is thus prescribed, but in the United States, where the
government is in no sense represented in the work, only favourable public
opinion can create that influence which serves in the place or" authority to
secure respect for the Pharmacopoeia and bring it into general use.

The Dispensatory of the United States — by George B. Wood, M.D.,
and Franklin Bache, M.D — was published January, 1833, fifty years ago.
They adopted the Pharmacopoeia of the United States as the basis of their
work.

" It is followed both in its general division of medicine, and in its alphabetical
arrangement of them in each division. Precedence is, in every instance, given
to the names which it recognizes, while the explanations by which it fixes the
significance of these names are inserted in immediate connection with the titles
to which they severally belong. Every article which it designates is more or less
described ; and all its processes, after being literally copied, are commented on
and explained wherever comment and explanation appeared necessary. Nothing
in fine has been omitted which, in the estimation of the authors, could serve to
illustrate its meaning,- or promote the ends which it was intended to subserve.
This course of proceeding appeared to be due to the national character of the
Pharmacopoeia, and to the important object of establishing, as far as possible
throughout the United States, uniformity both in the nomenclature and prepara-
tion of medicines.

"The nomenclature adopted by the different British Colleges, and their for-
mulas for the preparation of medicines, have been so extensively followed through-
out the United States, that a work intended to represent the present state of
pharmacy in this country would be imperfect without them ; and the fact that
the writings of British physicians and surgeons, in which their own officinal terms
and preparations are exclusively employed and referred to, have an extensive
circulation among us, renders some commentary necessary in order to prevent
serious mistakes. The Pharmacopoeias of London. Edinburgh, and Dublin have,
therefore, been incorporated, in all their essential parts, into the present work.
Their officinal titles are uniformly given, always in subordination to those of the
United States Pharmacopoeia, when they express the same object ; but in chief,
when, as often happens, no corresponding medicine or preparation is recognized
by our national standard. In the latter case, if different names are applied by
different British Colleges to the same object, that one is generally preferred which
is most in accordance with our own system of nomenclature, and the others are
given as synonyms. The medicines directed by the British Colleges are all de-
scribed and their processes either copied at length, or so far explained as to be
intelligible in all essential particulars.

" Besides the medicinal substances recognized as officinal by the Pharmaco-
poeias alluded to, some others have been described, which, either from the linger-
ing remains of former reputation, from recent reports in their favour, or from
their important relation to medicines in general use, appear to have claims upon
the attention of the physician and apothecary. Opportunity has. moreover, been
taken to introduce incidentally brief accounts of substances used in other coun-
tries or in former times, and occasionally noticed in medical books : and that the
reader may be able to refer to them when desirous of information, their names
have been placed with those of the standard remedies in the index "

The preceding paragraphs, taken from the preface of the first edition of
the Dispensatory, January, 1833, describe concisely and accurately the
character of the work when first presented to the public. It was in fact
the American expositor of the Pharmacopoeia of the United States, as well
as of the several Pharmacopoeias of Great Britain then existing, but since
merged into the British.

Fortunately for the success of the Pharmacopoeia, the authors of the
Dispensatory were eminently well cpialified in every sense to execute the
task they had assumed. The merits of their book were immediately re-

1883.] The Dispensatory of the United States of America. 217

cognized and secured for it a ready sale. Their excellent commentary on
the work enhanced the importance of the then young Pharmacopoeia of
the United States in the estimation of the medical public, and contributed
much towards establishing it as the national standard. In fact, every copy
of the Dispensatory sold placed a copy of the Pharmacopoeia also in the
hands of the purchaser, and thus the benevolent purpose of the authors
of the latter was assisted. There was no rivalry between the two works.
The mission of the Pharmacopoeia, so to speak, was fulfilled in the publi-
cation of the Dispensatory, which it had engendered. While it was ex-
tensively used, no one cared to urge the sale of the Pharmacopoeia. But
about the year 1870, some earnest but imperfectly informed thinkers began
to inculcate a fallacious notion that the success of the Pharmacopoeia could
be measured only by its sale ; and as not more than one copy of it was
sold to a thousand copies of the Dispensatory, it was plain that the pub-
lisher did not push the two works with the same interest or energy; and,
possibly, in other hands the Pharmacopoeia might be made to yield a
handsome profit to the compilers, especially if the Dispensatory could be
prevented from using or commenting on it. Yet, it is confidently believed,
that without the assistance which it gave, the Pharmacopoeia alone Avould
have failed in its sole purpose of securing its own recognition as the com-
mon standard of the country for all officinal preparations.

The welcome reception of the Dispensatory, and its progress in public
favour, were manifest in the necessity of a second edition, November,
1833, within ten months after the publication of the first. A third edition
appeared, June, 1836, and a fourth in June, 1839, each having been care-
fully revised and enlarged. Every subsequent edition fairly represented
at the time of publication the progress which materia medica and phar-
macy had made, always opportunely including the decennial changes in
the Pharmacopoeia.

Seemingly, the immense influence of the Dispensatory in establishing
the Pharmacopoeia, and its close and constant relations with it, have not
been considered of late, for we find on the back of the title page that
u Authority to use for comment the Pharmacopoeia of the United States
of America, sixth decennial revision, has been extended by the Committee
of Revision and Publication," implying that the copyright of the Pharma-
copoeia is no longer held for a purely benevolent and scientific purpose, as
it always had been.

The fifteenth edition of the United States Dispensatory follows the sixth
decennial revision of the Pharmacopoeia of the United States, which dif-
fers widely from preceding revisions in its general arrangement, and in
the method of its formulas. All the ingredients of each are stated in parts
by weight instead ot definite quantities, with the exception of formulas for
pills, in which they are stated in grains, and also in grammes. No mea-
sure of capacity is used. Whatever may be the advantages claimed for
this plan in theory, there are some objections to its practical use which
seem plausible at least, and, therefore, entitled to consideration. Dis-
pensing apothecaries, who make their own officinal preparations, as all
should, instead of purchasing them from a manufacturer, object to ,a for-
mula in parts by weight that it is not convenient, involves unnecessary
expenditure of time, because it requires a calculation for every operation,
a sort of translation of measures by weight into measures of capacity, and
that risk of error attends every such calculation. Formulas expressed in
definite weights and measures are more convenient to read and less liable

218

Reviews.

[July

to error in compounding. Besides, physicians will continue to prescribe
by measure as long as they must necessarily direct the administration of
liquids by measures of capacity, wineglass or spoonfuls. It is also objected
that at this time the addition to the pill formulas of the Pharmacopoeia,
the equivalents of grains in metric weights seems premature, to say the
least, and is, therefore, considered a mere surplusage of learned ornamen-
tation, which has no value in the practice of apothecaries generally, for
whose use the Pharmacopoeia is especially designed, and probably will
not have until the metric system of weights and measures alone is taught,
to the exclusion of all other weights and measures, in all American schools
of medicine and pharmacy, and the conversion of weights from one system
into another, which, like the conversion of currencies, is generally con-
sidered burthensome, ceases to be necessary. Then all prescriptions will
be written according to the metric system, because physicians will be
accustomed to no other; but there is nothing now apparent upon which to
found a reasonable conjecture that this is likely to be until after the
Pharmacopoeia has experienced many more decennial revisions — if ever.
Another criticism from the apothecaries' view is that the Pharmacopoeia
is no longer purely American, but has a foreign, continental tone, more in
harmony with our German than with our British brothers with whom we
are more congenial in our scientific ways and work.

In deference to such objections, the authors of the Dispensatory have
given, in addition to parts by weight, their equivalents of the formulae in
definite quantities, according to the established weights and measures.
The u officinal formulae have been adapted to the use of those pharmacists
who prefer the system of measuring liquids. The alternative formulas
have been carefully tested in practice." This concession to the views of
apothecaries will probably assist to maintain the observance of the Phar-
macopoeia as the standard of officinal preparations, though it may possibly
lessen its commercial value, which is of little importance comparatively.

The Dispensatory is divided into three parts. The first embraces all
the substances and preparations that are officinal according to the British
and United States Pharmacopoeias ; the second treats of drugs and medi-
cines which are not officinal, and the third part contains lists of chemical
tests, various tables and analyses of mineral spring waters of the United
States and foreign countries. A full index, which covers 78 pages, com-
pletes the volume.

The results of the labours and experience of the several authors, which
have been accumulating during a half century, are presented in the fif-
teenth edition of their work, which is a full and reliable repertory of all
the officinal materia medica recognized in the United States and British
Pharmacopoeias, as well as of very numerous matters, which, though not
officinal, are more or less employed in the practice of medicine and sur-
gery. No previous edition of the United States Dispensatory at the date
of publication was more worthy of commendation than is the present.

W. S. W. R.

1883.]

Holmes, 'Medical Essays.

219

Art. XXVI.— Medical Essays; 1842-1882. By Oliver Wendell
Holmes. 12mo. pp. x., 445. Houghton, Mifflin & Company, Boston.
New York, 1883.

It is permitted to few men to be prominent both in their professional
sphere and in the world of letters. Among those few, however, the name
of the writer of these essays is conspicuous — and the tenacity with which
Dr. Holmes has kept up his connection with the profession of his love,
even while receiving the plaudits of a world-wide arena, is shown by his
again issuing in collected-form essays which are purely technical.

Any one who takes up this neat and attractive volume and peruses the
essay upon homoeopathy, or the famous controversial one upon the con-
tagiousness of puerperal fever, will be at once struck with the fact that
the purity and vigour of style, the keenness and precision of statement,
with the genial wit ever bubbling to the surface, are marks of literary
ability pretty sure to seek exercise beyond professional limits.

It is unnecessary for us to comment upon the completeness of fulfilment
which has waited upon the promise of those early essays. The name of
Dr. Holmes is known wherever the English language is spoken, as one of
the brightest and most genial of living writers, and none are more proud
of him than his professional brethren.

It is, therefore, fitting that at a time when he is laying down profes-
sorial duties long and ably filled by him, we should add ours to the general
voice of congratulation, and express the hope that the rest so well earned
may be long enjoyed.

Most of these essays are of a semi-popular character, rather than direct
contributions to medical knowledge, but they deal with subjects upon
which every cultivated physician should be informed. The beauty and
mellifluousness of their style, as well as the cogency of their facts, make
them profitable reading for the spare hours which the most busy practi-
tioner must snatch from his round of occupation, and the hours thus spent
will slip speedily and pleasantly by. In the essay upon the contagious-
ness of puerperal fever, Dr. Holmes enunciates a doctrine which has been
very generally received, before the domination of the germ theory so
fashionable at the present day, and even those who may have felt disposed
to question the arguments of the essay, have very generally conformed
their life to the theory. Of those who were opposed to Dr. Holmes, it
may be said —

" The knights are dust,
Their swords are rust,
Their souls are with the saints we trust,"

and the unavoidable asperity of a controversial article falls, therefore,
somewhat harshly upon the ear, when the mind dwells lovingly upon the
memory of those who are gone.

But we have, said enough of a volume which will be eagerly read be-
cause it is the work of Dr. Holmes — and which, as we have said, will
surely give pleasure to every reader.

With Dr. Holmes's resignation of his chair at Harvard, and his publica-
tion of these essays, we may regard his professional career as closed. We
are happy to know that he is still active in the fields of general literature,
and while we congratulate him upon triumphs well Avon in the past, would
express the hope that he may long continue to labour in those fields effec-
tively. S. A.

220

Reviews.

Art. XXVII — A Text-book of the Diseases of the Ear and Adjacent
Organs. By Dr. Adam Politzer, Imperial-Royal Professor of Aural
Therapeutics in the University of Vienna, Chief of the Imperial-Royal
University Clinic for Diseases of the Ear in the General Hospital. He.
Translated and edited by James Patterson Cassells, M.D.,
M.R.C.S. Eng., Aural Surgeon to and Lecturer on Aural Surgery
at the Glasgow Hospital and Dispensary for Diseases of the Ear. 8vo.
pp. 800. Philadelphia: Henry C. Lea's Son & Co., 1883.

Prof. Politzer's well-known reputation as one of the first authorities
on diseases of the ear will lead the reader to expect something more than
an ordinary text-book in a work that bears his name, and he will not be
disappointed. As the translator says, it " treats of the whole science of
otology in the fullest and mos't exhaustive manner." Time and labour
have not been spared in its preparation ; it was issued in German in two
volumes, and four years have been consumed in the production of the
second. The anatomy, physiology, pathology, therapeutics, and bibli-
ography of the ear are so ably and thoroughly presented that he wrho has
carefully read this imposing volume can feel sure that very little of interest
or value in the past or present of aural surgery has escaped him.

A description of the anatomy of the ear and its development occupies
the first sixty pages, and is followed by a chapter on the physiology of the
sound-conducting apparatus. Then comes the practically most important
part of otology, the diseases of the middle ear, the author's classification
of which deviates somewhat from that usually employed. He opposes the
view of Gruber that the various forms of inflammation of the middle ear
are the same process modified by internal and external conditions ; as
anatomical investigation and clinical experience show that certain in-
flammations of the tympanum have peculiarities which give them a dis-
tinct clinical type and often determine the prognosis and treatment. He
thinks that much progress in our pathological knowledge will be necessary
before a strictly scientific classification will be possible, and prefers for
present use the classification on a clinical basis, assuming that for prac-
tical purposes it would be advisable to call those forms which run their
course without significant inflammatory phenomena, and with a discharge
of sero-mucous exudation, " catarrhs," and those forms which are accom-
panied by violent inflammatory phenomena, by formation of sero-purulent
or simply purulent secretion " inflammation." The inflammatory diseases
of the tympanum — the different forms of " otitis media" — are, therefore,
classified as acute inflammation of the middle ear, catarrh of the middle
ear, adhesive catarrh, acute purulent inflammation and chronic purulent
inflammation. It seems to us questionable whether this is an improve-
ment upon the nomenclature in general use, or is not more likely to lead
to confusion than to " define more clearly certain forms of inflammation of
the middle ear." A classification admittedly not strictly scientific, had,
perhaps, better be as brief and simple as possible, and as little at variance
with the generally accepted meaning of the terms that are used. It would
be no great loss to medical nomenclature if the terms " catarrh" and " ca-
tarrhal," which have been so much abused and distorted from their original
meaning, and have reached the height of absurdity in the expression "dry
catarrh," were dropped from it altogether.

Under the head of " the adhesive processes of the middle ear,,f a section

1883.] Politzer, Diseases of the Eye and Adjacent Organs. 221

of u catarrh is discussed that unfortunate condition upon which authors,
not being able to do much else for it, have been sufficiently liberal in con-
ferring names, as " otitis media catarrhalis chronica," " otitis media catar-
rhalis sicca," " otitis media sclerotica," " proliferous inflammation of the
middle ear," " otitis media iperplastica," " otitis media adhesiva lenti-
scens," etc. If called upon to add one more to the list, we would suggest
"opprobrium of aural surgery," as, call it what you will, it always makes
a very dreary chapter in otology. The affection of the labyrinth which so
frequently complicates this form of tympanic disease, the author thinks
is not usually of secondary origin. " With such decided labyrinthian
symptoms appearing even at the outset of the affection, we are from clini-
cal observation often driven to the assumption that both divisions of the
ear, the tympanum and the labyrinth, have been affected at the same time
and by the same disorders of nutrition. In the beginning of the disease,
however, the labyrinthian disturbances sometimes prevail to such an extent
that we must doubt whether in such cases the primary disease did not
originate in the labyrinth, and whether the development of the obstacles
to the conduction of sound did not occur later." Politzer has no doubt
as to the fact that certain patients hear much better in noisy places, a
symptom (paracusis, Willisiana) which has been the subject of much dis-
cussion, and the occurrence of which is denied by some good authorities.
He has satisfied himself on this point by experimenting upon a large num-
ber of cases, and has met with some. in which whispered speech was better
heard in riding than loud speech in rest and with quiet surroundings. He
has noticed this symptom almost exclusively in incurable forms of middle
ear disease. Thirteen or fourteen pages are devoted to the discussion of
" the operative treatment of the adhesive processes," but nothing very
encouraging is developed. After reading the pros and cons of artificial
perforation of the membrana tympani, with or without the uniformly fruit-
less efforts at maintaining a permanent opening ; multiple incisions of the
membrane ; tenotomy of the tensor tympani ; section of the posterior fold
of the membrane ; section of the anterior ligament of the malleus, etc., we
find nothing to disturb our melancholy assent to the dictum of Dr. Roosa,
that we are still without any operation that can rescue these cases from
the category of hopelessly incurable diseases. This statement was made
at the meeting of the American Otological Society for 1881, and met with
the active concurrence or silent consent of all present.

AVe are pleased to note that Dr. Politzer considers the " dry treatment"
of chronic suppuration of the middle ear, entirely discarding the syringe,
which has recently been somewhat ostentatiously paraded, singularly enough
as something new under the sun, applicable only to a very limited number
of exceptional cases. He also pronounces syringing by far the best means
for the removal of cerumen and foreign bodies — a stronghold in which
some restlessly advanced aurists have not hesitated to attack it. Though
aural therapeusis has long since passed that stage of development in which
it could be made the subject of such witticisms as that of the cynical
general-surgeon, who,. some years ago, proposed to divide diseases of the
ear into two great classes — 1st, those that can be cured by the syringe,
and 2d, those that can't — we still cordially agree with the statement
recently made by Dr. Knapp, that in a large proportion of cases of puru-
lent catarrh, thorough cleanliness is half the cure. In obstinate cases of
acute suppuration of the middle ear, particularly where the mastoid is in-
volved, Politzer strongly recommends injections of warm water through

222

Reviews.

[July

the Eustachian tube, by means of the catheter. His favourite local applica-
tions are boracic acid, in powder or solution, and, in cases of chronic sup-
puration with granulations of the tympanum, alcohol. In acute inflam-
mation of the mastoid he has obtained good results from the application of
cold by means of Leiter's coil of leaden tubes. The indications for Opera-
tive treatment of caries of the temporal bone and mastoid abscess, and the
important subject of otitic meningitis and cerebral abscess are thoroughly
discussed.

Othajmatomata are considered to have their origin usually in injury,
and their remarkable frequency in imbeciles is admitted, but no mention
is made of the insane in this connection.

There is an interesting chapter on the anatomy, physiology, and pa-
thology of the internal ear, which we have not space to more than refer
to. The author admits that " the physiological significance of the semi-
circular canals has not been made out, notwithstanding numerous ex-
perimental investigations on this subject," but sides with the view that
disturbances of coordination after injury of the canals proceeds from simul-
taneous injury of the cerebellum, or reflex transmission of irritation from
the ampullary nerves to the cerebellum. He objects to classifying as " Me-
niere's disease," all disturbances of hearing associated with subjective
noises and giddiness, and confines the term to cases of apoplectiform effu-
sion in the labyrinth, accompanied by the symptoms described by Meniere.

Disturbances of hearing from cerebral causes, which are usually con-
sidered very rare, the author thinks are much more frequent than has
hitherto been supposed, and the interest in his able discussion of this sub-
ject will by no means be limited to aural surgeons.

The thanks of the English-speaking part of the profession are due to
Dr. Cassellfi, for bringing this valuable book within their reach. He has
done a good work, and has done it remarkably well. G. C. H.

Art. XX VIII. — A Practical Treatise on Diseases of the Skin, for the Use
of Students and Practitioners. By James Nevins Hyde, A.M.,
M.D., Professor of Skin and Venereal Diseases, Rush Medical College,
Chicago; Dermatologist to the Michael Green Hospital, Chicago, etc.
8vo. pp. 572. Philadelphia: Henry C. Lea's Son & Co., 1883.

In face of all the activity in book-making in dermatology recently dis-
played, not only here at home, but in France, England, and Germany,
resulting in the production of so many valuable treatises, it may well be
asked at once, Was there need of another work of this kind? Certainly
no one should feel authorized to write it who has not a large experience
to call upon, a proper judgment to select the real and valuable in the obser-
vations of others, and the method of presenting his subject-matter which
marks the successful teacher. These qualifications the author has shown
himself to possess abundantly, and he has given the student and prac-
titioner a work admirably adapted to the wants of each. It has been his
endeavour, he says, to " set forth only what can be held as the truth, to
be frank in the admission of the weakness with which the most skilful
physician stands in the presence of many grave and not a few benign dis-
orders, and to cultivate a wholesome doubt of that which has not been

1883.]

Hyde, Treatise on Diseases of the Skin.

223

shown to be worthy of trust ;" and well has he carried out his purpose,
especially in the last respect.

Although the book is dedicated to Professor Kaposi, Hebra's collabo-
rator and successor in the Vienna chair of Dermatology, and may perhaps
be called an exponent of the German school, it is no man's book but the
author's, and its individuality is very strong. It is of the German school
only because, like that, it takes little for granted which rests upon guess-
work and theorizing, and not uj;on simple observation. Therefore the
author gives full credit and indorsement to the researches of his colleagues
in all parts of the world, and little seems to have escaped his study ; but
he lacks veneration for the mere doctrines of even the most distinguished
of them in a refreshing degree. Accordingly in etiology and theoretical
therapeutics the book may seem to some unsatisfactory, as it fails to fur-
nish a cause or several reasons for the existence of each affection, and to
recommend for its cure the administration of remedies consistent with
them. In place of such matter we have a frank avowal of our present
ignorance of the causation of a large part of the diseases of the skin.

The first part of the volume is general in character and treats of anatomy,
symptomatology, etiology, diagnosis, prognosis, therapeutics, and classifica-
tion. The chapter on anatomy is based upon the recent investigations of
the most reliable workmen in this field, and is illustrated by well chosen
cuts. The descriptions are brief, and occasionally a little vague, as when
the author states that "there is strong reason to believe that the odorous
emanations from the skin are the sole sources by which several of the con-
tagious and infectious diseases are communicated from one individual to
another." In describing the forms of cutaneous efflorescence he prefers
to call them lesions and lesion relics, instead of using the terms commonly
employed, primary and secondary lesions, although we fail to see the advan-
tage of the innovation. No such words can exaclly define the mutual
relations of the various forms of eruption in respect to evolution and invo-
lution. A useful glossary of ninety of the terms employed to describe the
shape, variety, etc., of eruptions is appended to the chapter, which might
have been extended with advantage.

The subject of general etiology is treated briefly, for, as above stated,
the author has been satisfied with telling his readers only what is known
with regard to it. He has no pet theories to maintain, he does not believe
in undemonstrable dyscrasies, or recognize the necessary existence of
invisible connections between the diseases of the skin and the other organs
and fluids of the body. In other words, he sees nothing exceptional in
cutaneous pathology in its relations of dependence to the general economy.
In the chapter on general diagnosis the directions given with regard to
methods to be used in determining the nature of individual affections are
excellent in point of explicitness.

The author's views on internal therapeutics may be well stated in his
own words : —

"There are no remedies to be given by the mouth which can be described as
" certainly and specifically curative of the diseases of the skin. The number of
medicinal agents employed with this end is incredibly large, . . . but, with
the few exceptions given below, not one of these is known to exercise the slight-
est remedial action upon the surface of the body. . -. . Those possessed of
some value are arsenic, mercury, iodine, cod-liver oil, quinine, ergot, and carbolic
acid. Of them all, it may be said that, while each possesses a wide range of use-
fulness, no one of them in any case can be certainly trusted to produce a given
effect; and each, in many cases, is either positively prejudicial, or without effi-
cacy of any kind."

224 Reviews. [Jul}'

It will be seen that he recognizes no " specifics" or routine remedies :
none the less will it be found that his treatment is thoroughly satisfactory
in its completeness and practical minuteness. We know of no more judicious
guide to be followed by the practitioner in the management of the most
unmanageable affections of this class.

It is hardly to be expected that any one will write a book on dermatology
and refrain from trying his hand at a new system of classification \ however
much he may, at the same time, lament the great number already in exist-
ence. The scheme of the author is based upon that of Hebra in the main, the
affections being redistributed according to the regions or tissues involved.
It recognizes ten classes, as follows: 1. "Involving predominantly the
component parts of the epidermis and derma, and incidentally the appen-
dages of the skin." Under this are arranged a majority of the hypenemic,
exudative, hypertrophic, atrophic, and neoplastic processes of the skin. 2.
Of the sebaceous glands and periglandular tissues. 3. Of the sweat glands
and periglandular tissues. 4. Of the hairs, hair-follicles, and perifollicu-
lar tissues. 5. Of the nails. 6. Of the blood and lymph vessels and
perivascular tissues. 7. Of the nerves. 8. Of the pigment. 9. Of the
skin with involvement of other organs. 10. Of the skin and its appen-
dages, all parasitic. Although, on some accounts, it may be convenient
to find all diseases of any one anatomical structure considered together,
yet the more important pathological relationships are thus violently put
asunder, and absolute consistency in such an arrangement is impossible,
as disease does not limit itself to any one structure or region in most cuta-
neous affections. There is no good reason made apparent for the creation
of class 9, or for the separation of the diseases of which it is composed from
those of a similar nature in class 1.

In the second part of the volume individual diseases are treated of in
the order indicated in the above classification, and in the usual method.
The descriptions are generally clear and graphic, and due attention is given
to the structural changes, which are often illustrated by cuts taken mostly
from the works of recent investigators in this field of research. It is the
treatment which the author has presented with the greatest fulness, and
here certainly nothing has been omitted which an extensive knowledge of
the literature of the subject, and especially a large experience with the
materia medica of dermatology could supply. He has, as a rule, tried to
prove all things before recommending them to his readers, and has only
occasionally advised the use of remedies the merits of which rest upon
mere theory or insufficient evidence.

Our comments upon his presentation of the various affections must be
brief. The varieties of erythema seem to us to have received far too little
attention, some of them being noticed almost by title only, erythema nodo-
sum even being dismissed with but eight lines. Dr. Hyde recognizes four
principal clinical types of eczema, the erythematous, vesicular, pustular, and
papular, with, of course, other varieties according to seat, cause, duration,
etc. He expresses the opinion, contrary to that held by most dermatologists,
that it is not first in order of frequency among cutaneous diseases, but that
it occupies a second rank in this respect to acne. He holds this belief, in
spite of statistics, " by observation of the faces of individuals on the streets
of any large city." This might possibly teach us that acne of the face is
more common than eczema of the face, certainly nothing more, for eczema
of every other part of the non -exposed surface is extremely common,
whereas acne rarely affects any portion of the body when the face is exempt.

1883.]

Hyde, Treatise on Diseases of the Skin.

225

Acne, moreover, occurs to any great extent only during a limited period of
life, while eczema spares no age. But statistics are more reliable than
impressions, and in this direction their teachings cannot be misinterpreted.
Of nearly sixty thousand cases of skin disease, taken from the private and
dispensary practice of approved dermatologists in the United States, eczema
formed 31.5 per cent., while acne formed but 7 per cent. ; and in Europe,
in 48,000 cases of the same class, reported by well-known dermatologists*
eczema occurred in the ratio of 23 per cent., acne in 2.-4 per cent. The
author's views regarding the much-discussed etiological relations of eczema
to local or general conditions of the system may be best given in his own
words : —

" Eczematous affections occur in the persons of individuals who are in every
respect superb examples of good health. They occur also in persons who are-
affected with every form of bodily ailment ; such coincidences, however, scarcely
furnish a satisfactory etiological basis, unless a certain degree of constancy be-
tween eczema and these disorders could be established. It should be added that
every phase of eczema can be artificially produced upon the surface of the skin
by the action of external irritants. Several authors take exception to- this view,
claiming that the induced disease is an artificial dermatitis, but they fail to point
out the distinctive objective differences between such dermatitis and eczema.
They content themselves with observing the subsequent evolution of the malady,
and pronounce that to be an eczema which fails to respond promptly to treat-
ment, and that a dermatitis which is capable of speedy relief.. The climax of
such absurdity is reached when they are shown obstinate cases of eczema of arti-
ficial origin, and the response isr that the induced dermatitis gave rise to an
eczema in a predisposed subject."

The treatment of the disease laid down is consistent with these views
of its etiology, viz., " there is no constitutional treatment of the diseases
save that which excludes all sources of irritation." We rind, accordingly,
but one drug credited with any power over it when administered internally,
viz., arsenic, and this receives but faint approval.

"It has been my ill fortune," he says, "to observe so many obstinate forms
of squamous and papular eczema aggravated by its employment, that I should
consider an acquaintance with a dozen patients relieved by its use in a single
year a circumstance suggestive of as much curiosity as congratulation."

His directions for the use of local remedies, on the other hand, are ex-
haustive, and given with minute detail. Stress is laid upon the necessity
of soothing management as the most important guide in our choice of ap-
plications. The special treatment for local forms of the affection is well
given.

In connection with his remarks on herpes progenitalis?.the author states
his belief that it is " always the result of naturally or unnaturally induced
erethism." How proximately this relation is supposed to hold he does not
state. It certainly occurs in some cases as an almost constantly recurrino-
or permanent affection for several years, and without any immediate sexual
element of causation. He recognizes the individuality of the pseudo
herpes iris, more appropriately to be regarded, we thinks as an erythema
bullosum. In the grave prognosis he attaches to herpes zoster, he un-
doubtedly intended that his remarks should apply to the facial form only.
In his remarks upon the etiology of impetigo contagiosa, he states that it
" must first at least occur in the skin of a patient who has lately suffered
from a contagious disease (varicella, variola, vaccinia}." We should say
that either his definition or experience was too limited, for its coincidence
No. CLXXI July 1883. 15

226

Reviews.

[July

with such affections under our observation is certainly very rare in com-
parison with its whole occurrence.

To his description of the "primary lesion " of psoriasis — that it is a ma-
cule of " reddish-brown" tint — we must also object as inaccurate, for the
redness which characterizes the hyperaemia is generally as fresh coloured
in the beginning as in any other inflammatory process of equal grade, and
the duller colour alluded to marks and is caused by the chronic duration
of the efflorescence. The author differs, too, from most writers in the
opinion he expresses that the disease is not hereditary. He displaces
pemphigus foliaceus from its connection with simple pemphigus, and gives
it a close alliance with pityriasis rubra, on very insufficient grounds it
seems to us. The so-called molluscum contagiosum, in accordance with
a majority of the latest observers, he places among the hypertrophies of
the epithelial layer, but there is no apparent reason why it should be sepa-
rated from other keratoses. The plate illustrating the affection seems to us
ill-chosen. In his very brief description of elephantiasis we looked for some
account of the recent and very interesting investigations upon the fllarise of
the blood of patients and musquitoes, but in vain. The author adheres
to the very inappropriate name xeroderma to denote the little understood
affection entitled angioma pigmentosum et atrophicum by the American
Dermatological Association, which has at least the merit of being descrip-
tive. The retention of the term molluscum in connection with fibroma of
the skin is also to be regretted, as tending to perpetuate confusion in
nomenclature. In explanation of the more frequent occurrence of bald-
ness in men than in women his reason is hardly satisfactory. " The lat-
ter," he says, " usually wear an exceedingly light covering for the head,
while men encase the latter with tight-fitting caps, which interfere with
proper aeration of the scalp." Per contra, men wear their hair short ; bald-
ness affects, we should say, men of sedentary habits, who keep their heads
mostly uncovered, rather than out-door labourers ; and women cover up a
large part of the scalp with thick braids, etc., which must cause the heat
of these parts to be largely retained. The causes of this sexual inequality
must be sought in other conditions apparently. In connection with the
causes of alopecia areata, the author dismisses the parasitic theory very
abruptly, with the statement that no parasite can be discovered. It might
be considered due to the character of the by no means few and even recent
observers who claim that they have found it, that the statement should
have been made, at least, that a difference of opinion exists upon this point.
In connection with the pigmentary affections, the author expresses the
very surprising opinion that in vitiligo "the changes are probably due to
the influence of the sweat in washing the pigment to the surface."

Dr. Hyde does not believe in the contagiousness of leprosy, but cer-
tainly in these days of its revival in our midst we need stronger evidence
in rebuttal of the testimony presented in support of this doctrine by
modern instances than references to confused biblical accounts simply.
Neither does he recognize any etiological relations in the occurrence of
the so-called bacillus lepra ; indeed, he regards its presence in leprous
tissues as accidental, not constant, and itself as " identical with the bac-
teria which form in an infusion of hay." He adds in a foot-note that the
forms presented by the bacillus lepras and bacillus tuberculosis can be arti-
ficially produced by the formation of rod-like crystals of margaric acid.
This, to say the least, is a very summary way of disposing of the results
of the investigations of many scientific observers, who are perfectly com-

1883.]

Chatin, La Tri'chne et la Trichinose.

227

petent to distinguish one form of growth from another, and who are in-
capable of mistaking a crystal for a plant. The question of the parasitic
nature of leprosy is not yet solved, but it is in trained and reliable hands.

The chapter on the syphilodermata is one of the best in the book, the
descriptions being graphic, and the directions for treatment given with
great detail and care. In his remarks upon the etiology of the vegetable-
parasitic diseases, he seems to attach weight to the opinion expressed by
some writers — that an appropriate soil is needed for the germination of
the fungus, "some individuals being thus predisposed to its invasion."
On another page he says : —

" I lately treated a physician for ringworm of the bearded chin and cheek,
derived from the face of a little patient under his care. He subsequently gave
tinea circinata to his wife, who suffered on the face and shoulder, and she, in
turn, communicated tinea tonsurans to her daughter."

Such observations could be supported by much more striking instances
of the indifference of the parasite to the personality of its host, when the
conditions for its attachment are favourable.

There are, of course, many other points of minor importance upon which
the author and his critic might differ, but we can heartily commend the
book as a valuable addition to our literature, and a reliable guide to
students and practitioners in their studies and practice. J. C. W.

Art. XXIX La Trichine et la Trichinose. Par Joannes Chatin,

Maitre de Conference k la Faculte des Sciences de Paris. Professeur
Agrege a l'Ecole Superieure de Pharmacie. Avec 11 planches. Paris :
J. B.^Bailliere et fils, 1883.

France has enjoyed a singular immunity from trichinous disease, and
the interest in the subject was purely scientific until the occurrence of a
few cases, and the suspicion that American pork was to blame aroused
public alarm, and the question has now become one of almost international
importance. By a decree of February 15, 1881, the importation of salted
meats from America was prohibited, but as almost all of it was consigned
to Havre, it was decided to establish a laboratory of inspection at that port
and submit every piece of pork to microscopical examination. M. Chati
was appointed director of the laboratory, and for four months super-
intended the observations. This work is largely the outcome of the expe-
rience thus obtained, and is a tolerably complete monograph on the life
history of the trichina, and its relations to public health.

The results of the work at Havre are of special interest to us. A staff
of about forty examiners was employed, and the mode of procedure was
to open the casks or barrels, take a specimen from each piece, carefully
mark both, and then cut eight or ten sections, and examine in weak" salt
solution with ar power of about 70 diameters. If the specimen was found
infested with trichinae, the piece from which it was obtained was picked
out and destroyed. It was found that one person could examine about
twelve casks in the day, each containing twelve long sides of bacon.

In all, 7418 casks, barrels, or crates were inspected, containing 103,528

228

Reviews.

[July

pieces, with the following results: In one set of 3444 barrels 14.00 per
cent, contained trichinous meat. Of the 53,318 pieces in these barrels,
1087 were affected: i. e., 2.03 per cent. In another set of 3974 barrels,
14.64 per cent, contained infested pieces, and of the entire pieces, 50,210
in number, 1.97 per cent, contained trichinae. Long sides, short sides,
shoulders, and hams, made up the great bulk of the meat, and the percent-
age ranged from 1.29 in the hams, to 2.49 in the short sides. Trichinae
were found in 14 out of 15 casks of sausages, and in two casks of intestines
the parasites were detected encysted in the muscular walls of the bowels.
The ratio here given corresponds closely with that found in Germany in
1879, when 2 per cent, of American pork and 1.9 per cent, of native hogs
were found trichinous.

These foreign results are not surprising with the records before us of
the inspections which have been made in this country. Mr. Billings, of
Boston, found, in a large number of examinations (over G000), the pro-
portion of trichinous hogs in the different groups from 1 in 17 to 1 in 44.
We do not know on what authority the statement, quoted by M. Chatin,
is made that the Chicago Board of Health estimated 8 per cent, of the
hogs slaughtered in that city to be affected, but there can be no doubt,
even from the limited investigations which have been made, that the
trichina prevails to an alarming extent in western animals. No wonder,
with the Havre record before them, the French do not want American
pork, not only on account of the possible danger of direct infection, but
also from the likelihood of contamination of the native stock, so far re-
markably free from the disease.

Among points of interest discussed in the volume, a few may be men-
tioned. The belief prevails widely that the trichina? are confined to the
muscular system, and do not infest the connective tissues and fat. M.
Chatin and his staff have frequently found them both in the natural fat and
in lard, and have produced the disease by feeding these substances to ani-
mals. An important question is the effect of the salting and smoking pro-
cesses on the vitality of the parasites. Though prolonged pickling may kill
them, the experience at Havre clearly shows that the ordinary processes
of curing as carried out in this country have but little influence. Repeated
experiments proved that animals were readily infected when fed with por-
tions of salted or smoked ham and bacon containing the parasites. One
experiment of Fourment is worth noting, as it demonstrates the power of
resistance to salting possessed by trichina?. On the 19th of April, 1881,
a piece was taken from an infested side of bacon, placed in a bottle,
covered completely with salt, and the cork sealed. It was opened on the
1st of April, 1882, and the piece removed. After soaking in water for
several hours, portions of it were fed to a mouse on the 4th, 5th, and 6th
of April. The animal died on the 7th, and perfectly developed sexual
trichinae were found in the intestines. A second mouse, fed in the same
way, died on the 13th day. It is evident that the pickling processes offer
very slight protection, if, indeed, they have any influence whatever on the
parasites. It is well known that many of the epidemics have been caused
by eating smoked and salted ham or bacon. In the section on the action
of heat and cold in the trichinae the author brings forward many facts to
show that even in an apparently well-cooked piece, the temperature may
not, particularly if it is a large joint, have been sufficient to kill them. In
thick portions like hams, it is difficult, even on prolonged boiling, to get
the central parts to a temperature adequately high. This may explain

1883.J

Allen, System of Human Anatomy.

229

the fact that in certain outbreaks those who partook of the .infected flesh
were unequally affected, some slightly or not at all, others severely, de-
pending, no doubt, on the portion of the joint of which they had eaten.

These thorough and careful French investigations, should receive the
attention of the government and of the large western packers, as they give
an additional warrant to European countries of the dangers of American
pork, and justify the prohibitory measures which many of them have
adopted. When a trade is interfered with, pressure enough can usually
be exercised to have suitable inquiries made, and reforms effected, if not
in the interest of public health at least in those of commerce. An official
compulsory inspection should be instituted in the large pork-packing
establishments which would in the first place give more satisfactory evi-
dence than we have at present of the degree of infection of our hogs, and
would, moreover, do much to remove the alarm at present existing in
Europe. Without it the present embargo is not likely to be cancelled.
Endeavours should be made to establish the mode of infection of the
animals, and the period at which they get the disease. These are ques-
tions as yet unsettled, but upon which a committee of investigation might
obtain valuable evidence.

The enormous losses entailed by the compulsory slaughter of cattle at
the ports of debarkation, and by the embargo which has been placed on
American pork, should open the eyes of our legislators to the importance
of taking proper measures to prevent the spread of existing animal plagues,
or to stamp them out altogether. It is surprising, considering the vast
stock interests of the country, how far behind we are in the study of com-
parative pathology, and in all matters of veterinary police and quarantine.
Let us hope that the steps in this direction which the government has
taken in the past few years, indicate that at length public opinion has
reached a point which makes the necessary legislation not only prac-
ticable but imperative. W. O.

Art. XXX.— -A System, of Human Anatomy, including its Medical
and Surgical Relations. By Harrison Allen, M.D.*, Prof, of Pby-
siologv in the University of Pennsylvania, etc. etc. Philadelphia:
Henry C. Lea's Son & Co., 1882-3.

, Few professional books, perhaps none, have ever been published in this
country the appearance of which was more eagerly looked forward to than
the one under review. For years " in preparation" and " in press," it is
now issued not as a completed work but in fasciculi, four of which are in
the hands of our readers ; the first being devoted to histology, and written
by Dr. Shakespeare ; the second to the bones and joints ; the third to the
muscles : and the fourth to the heart and bloodvessels.

The scope of the work is far beyond that usual to treatises on Anatomy,
the author's aim being to present to his readers not only anatomical de-
tails, but such practical applications and illustrations as must serve to fix
the facts in mind and show the great value of accurate knowledge of the
structure and relations of the various parts of the body in the diagnosis

230 Reviews. [July

and treatment of their diseases and injuries. Reserving all remarks re-
specting the real value of the work as a text-book for students and refer-
ence volume for practitioners until such future time as we shall have it in
its entirety, we will now merely notice certain of the statements that have
attracted our attention in a rather hurried reading of the issued parts.

Before doing so, however, a peculiarity of anatomical nomenclature
must be referred to, one which will, we fear, prove confusing if not posi-
tively misleading to many readers. Instead of the ordinarily employed
inner and outer, internal and external, we lind substituted median and
lateral; and further, in the limbs the line of reference is not the long axis
of the body, but that of the limb itself. We shall see hereafter when re-
ferring to the relative positions of the femoral artery and vein, how readily
this change in nomenclature, scientific though it may be, may work mis-
chief to students and patients.

Section 1, devoted to histology, and written by Dr. K. O. Shakespeare,
presents in a clear and succinct manner the general characteristics and
peculiarities of the various tissues, and is well illustrated by numerous
figures well selected and clearly drawn.

In section 2, the largest ot any as yet issued, the bones and joints are
treated of; and it is full of -practical references and suggestions. Though
occasionally incorrect statements arc met with, they may without doubt be
attributed to defective proof-reading. For example, though when treating
of the sacrum it is declared that the posterior surface is narrower than the
anterior, later on we find that " the sacrum being broader behind than in
front would slip forward if the motions were not checked by the stout
ligaments uniting it with the innominate bone." Again, in describing the
ulnar the external lateral ligament is stated to be attached to its styloid
process,, while in treating of the wrist-joint ligaments the internal lateral
is given as attached to the " spinous process of the ulna ;" to the scaphoid
tubercle it is in one place declared that the internal lateral ligament is
attached, in another the external; and to the cuneiform the external
lateral (p. 180), the internal (p. 224). Again, the smooth anterior sur-
face of the upper third of the tibia receives, we are told, " the aponeurosis
made up of the expanded tendons, of the sartorius, the gracilis, and the
semi-membranosus." Such errors as these have evidently resulted from
oversight in proof-reading ; as also others in various parts of the work,
such as labium major (twice repeated in one paragraph), pubis, septce, etc.

Section 3, devoted to the consideration of muscles and fasciae, occupies
nearly a hundred pages, and is illustrated by many plates of varying
degrees of excellence, not a few of them being of decidedly inferior
character.

As usual, the occipito-frontalis is described as a double-bellied muscle,
with its broad aponeurotic middle portion. It certainly ought to be re-
garded as two independent sets of superficial muscular fibres inserted into
the deep fascia, and serving as tensors and movers of the same.

The buccinator is declared to belong " more properly to the pharyngeal
constrictor group ;" and the office of the tensor palati probably to be to
dilate the orifice of the Eustachian tube. The insertion of the sterno-
clei do -mastoid is given as the mastoid process, and its use to flex the head
on the neck, neither of which statements, while the truth, is the whole
truth. The quadratns lumborum, instead of being " incised in colotomy
and in nephrotomy," ought, by its outer margin, to furnish a starting point
for the deep cut, whether made obliquely or transversely. The rhomboids

1883.]

Allen, System' of Human Anatomy.

231

are regarded as antagonists of the serratns magnns, instead, of serving to
carry the insertion of the latter over to the spine.

Though reference is duly made to the occasional congenital absence of
so much of the long head of the biceps cubiti as lies above the bicipital
groove, as also to its absorption in certain cases of chronic rheumatoid
arthritis, neither in this section nor in that on the ligaments is it shown
that, probably, it is primarily a shoulder-joint ligament, the action of
which is greatly intensified by its connection with the muscle ; and that
anatomically, and especially pathologically, it has strong analogies with
the ligamentum teres of the hip-joint. The flexor carpi ulnaris is stated
to be supplied by the median nerve.

In the paragraphs on inguinal hernia, the direct variety is declared to
push before it the conjoined tendon, though notice is taken of Agnew's
doubts upon this subject. How is it possible for a firm layer of white,
fibrous, non-elastic tissue to be pushed ahead of a knuckle of bowel or a
mass of omentum, and carried beyond the external abdominal ring?
Where is there a record of a post-mortem examination which has un-
questionably proved that what is apparently an anatomical impossibility
may be a pathological verity? Though we have long and faithfully
searched for such, we have never found it; nor indeed do we ever expect
to. For the relief of a constricted femoral hernia, either Hey's ligament
or Poupart's ligament is said to require nicking, no mention being made
of Gimbernat's, which much more often than Poupart's is the one re-
quiring to be cut. In fracture of the coracoid (!) process of the ulna,
we find it written that " the severed tip is drawn upward by the brachi-
alis anticus" though, in fact, the muscle is not attached to the tip but the
basal part of the anterior surface.

Section 4 is devoted to the consideration of the vascular system. On
page 338 it is stated that " Dr. J. H. Brinton and Mr. Rivington, how-
ever, have demonstrated the presence of a valve at the junction of the
right spermatic and the renal veins;" later on (page 436), Brinton's and
Rivington's views are correctly stated. The transverse portion of the
arch of the aorta we find to extend " from the right second costal carti-
lage to the intervertebral substance between the fifth and the sixth dorsal
vertebrae," and the descending portion "from above the tracheal bifurca-
tion at the second dorsal vertebra to the lower border of the third dorsal
vertebra."

The student who reads the following paragraphs will, we are sure, get
a curious idea, if any at all. " The right (carotid) artery arises from
about the level of the second dorsal vertebra. As it lies within the thorax
it is more superficial than the left, and is seen at its origin nearly in the
median line, but inclines to the right and lies at the base of the neck
behind the sterno-clavicular articulation. Over it is the right innominate
vein. The subclavian vein lies to the outer side. The left artery is
longer than the right, and is the more deeply seated. It ascends nearly
vertically, and lies on the trachea and oesophagus. Behind it is the tho-
racic duct. It is crossed by the right innominate vein."

The communicans noni nerve is stated to sometimes lie within the
sheath of the great vessels; though it is true that, occasionally, the junction
of the communicans and descendens takes place within the sheath, is it not
the latter nerve which is here referred to? Direction is given to expose,
when practicable, the external carotid " at its origin from the common
carotid to be sure of ligating the main trunk below the point of origin of

232

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[July

the superior thyroid ;" the point of election in the ligaturing of this vessel
is between the superior thyroid and the lingual. The internal mammary
passes " downward beneath the pleura along the posterior surface and
near the border of the sternum." If so, how and where is it to be tied ?
The posterior interosseous is located below instead of between the super-
ficial and deep layer of muscles. The origin of the middle hemorrhoidal
is given as from the first stage of the internal pudic. In the statement
of Holden's direction for finding the gluteal artery, the trochanter minor
is given instead of major. In ligaturing the common femoral, this needle
is directed to be passed "from without inward, to avoid the vein which
lies to the outer side of the artery.'' Correct as this statement is, using
the terms inner and outer as the author does with reference to the median
line of the limb, it is so directly contrary to what is usually understood
that it is to be regretted that the terms were employed at all ; for by the
majority of readers their meaning will certainly be misapprehended. No
notice is made of the possible origin of the deep epigastric from the pro-
funda. The nutrient artery of the tibia is stated to be a branch of the
peroneal. The anterior tibial in the lower portion of the leg is declared
to lie between the tibialis anticus and the extensor longus, and to be
crossed at the ankle by the tendon of the tibialis anticus muscle. In the
ligation of the upper part of this artery the line of direction, it is said,
"can be defined by exciting contraction of the tibialis anticus muscle,"
no reference being made to the white line which so generally marks the
first intermuscular space. P. S. C.

Art. XXXI Quain9 s Elements of Anatomy. Edited by Allen

Thomson, M.D., D.C.L., LL.D., F.R.S., Edward Schafer, F.R.S.,
and George Dancer Thane. Ninth Edition. 2 vols. 8vo., pp. xiii.,
748, and ix., 947. New York : Win. Wood & Co., 1882.

Nine editions and eight authors and editors attest unusual worth in
any work originally published by Dr. Jones Quain, who also revised
the following three editions. The work has passed through the hands of
such men as Richard Quain, Sharpey, Ellis, Cleland, and the present
editors. Comparing the earlier editions and the present one, it is sur-
prising to see how the book has changed. Like the boy's penknife,
first the new blade, and then the new handle, and yet still the same
knife, so in successive editions, additions, alterations, and improvements
have left but little of the original save the title. Unquestionably, it is
the foremost work on Systematic Anatomy published in the language.
The first volume contains the anatomy of the bones, joints, muscles,
bloodvessels and nerves, and of the superficies of the body, and has been
revised by that accomplished anatomist Professor Thane ; the second
volume contains, histology and splanchology, which have been revised by
Professor Schafer, eminently fitted for the work as a physiologist, and
embryology, which has been revised by the veteran Professor Thomson,
who has been associated with the two previous editions of the work. A
number of the old cuts have been displaced to advantage, and in any
later edition we trust this work of substitution will be still further carried

1883.]

J e n N I x G s , Transfusion.

233

out. for any one who will compare the older cuts with the later, and espe-
cially with the reproductions of Hirschfeldt's plates from Sappey, will be
struck with the great improvements thus effected. If Mr. Heath's plan with
numerical reference marks were followed, of having all the odd numbers
in succession on one side, and the even ones on the other, it would also
be a great improvement.

Moreover we object to " highly magnified," " much magnified," and
similar terms so often employed in the explanation of the cuts. Where
they are borrowed it is often perhaps unavoidable, but in original cuts such
indefinite terms are always to be avoided ; the precise power used should
be stated. In no other way can exact knowledge be imparted.

We do not like the plan of separate indexes for each volume, and,
moreover, they are not as full as they should be, but when we compare
them with French works we are satisfied. For accurate proof-reading
we have never seen a better book ; only three misprints are noted in the
"errata," and in a pretty thorough examination of the text, we have not
discovered a fourth. As to the text there is little to be said save in com-
mendation. Any book nearing its decade of revisions has received the
stamp of professional approval that would outweigh any criticism. We
can especially commend the bibliography of recent literature, which is
added to each part, as a most useful and valuable point. This is particu-
larly full in the section on embryology. W. W. K.

Art. XXXII. — Transfusion : Its History. Indications, and Modes of
Application. By Chas. Egertox Jennings, L.R.C.P. Lond., etc.
With Engravings illustrating the Author's Siphon for Intravenous In-
jection and Immediate Transfusion, and a Bibliographical Index. 8vo.
pp. viii. 69. London : Balliere, Tindall, and Cox, 1883.

The introduction of this very interesting monograph opens in the fol-
lowing graphic and attractive way : —

" Students, with smiling faces, are rapidly leaving the theatre of one of our
metropolitan hospitals. The most brilliant operator of the day has just performed
immediate transfusion with the greatest success. By means of a very beautiful
instrument, the most complex aud ingenious that modern science has as yet pro-
duced, a skilful surgeon has transfused half a pint, or. perhaps a pint, of blood
from a healthy individual to a fellow-creature profoundly collapsed from the
effects of severe hemorrhage. Some little difficulty was experienced prior to the
operation, as one of the many stopcocks of the transfusion apparatus was found
to work stiffly : but this error was quickly rectified by a mechanic in attendance.
Towards the close of the operation the blood-donor, a powerful and heavy young
man, swooned. Two porters carried him into an adjoining room, his wounded
arm being bandaged up, secundum artem. by energetic dressers. Diffusible
stimuli were exhibited by the mouth, nostrils, rectum, and skin. The man ral-
lied in due course, being well cared for by a group of students and nurses deputed
to look after him. The wound in his arm will probably heal speedily, or a few
weeks later he may possibly apply at the out-patient department of the hospital,
presenting an ugly-looking, pulsatile tumour, associated with a thrill and rasping
bruit, connected with the vessels in the cubital triangle, a most unfortunate acci-
dent having clearly happened here, of which a record promptly appears in the
columns of the Lancet.'''

234

Reviews.

[July

This account is followed by the narration of an imaginary case of post-
partum hemorrhage, occurring under the care of a solitary practitioner in
the country, where none of the conveniences of the brilliant operation are
at hand, and where disappointment and discredit are the consequence of
the attempt to imitate it. Then the question is put, whether or not the
operation of transfusion can be considered one of universal applicability.

Objections founded upon cases in which death soon results, the author
treats with a certain amount of scorn, insinuating that intra-uterine injec-
tions of hot water may have led to air entering the uterine sinuses, falsely
charged to the transfusion, or that similar injections of perchloride of iron
may have given rise to an embolus, no blame attaching to the transfusion
apparatus.

Nevertheless, he recognizes the importance of the objections urged against
transfusion, and advises meeting them by simplifying the operation. The
first step in this simplification consists in dispensing with blood, and em-
ploying an artificial substitute. The second consists in using an uncom-
plicated apparatus.

The chapter on the History of Transfusion is brief, but interesting, the
earlier attempts indicating, what has since been apparently clearly proved,
that the admission of a moderate amount of air into a vein cannot be re-
garded as necessarily fatal to the recipient. For, in all the experiments of
Lower, in England, in 16G5, the communication between donor and re-
ceiver was made by a number of quills, which were joined together after
being connected with the " Carotidal arterie " of one dog and the " Jugular
vein " of another — air of course, filling all the quills.

In the chapter on the Prospects and Indications of Transfusion nearly
fifty per cent, of recorded cases are said to have recovered. This estimate,
however, is founded upon a combination of several tables of statistics,
which may have contained duplicates. Yet, even if a much smaller pro-
portion of such operations were successful, it would warrant the attempt
to save life by means of it.

The reading and experience of the author lead him to conclude that the
direct method of transfusion is only applicable to a small number of cases,
and only practicable with skilled assistance and hospital appliances. The
causes of failure of the operation, he thinks, can all be obviated, and that
its dangers " are not greater than those which attend venesection and
other minor operations on the venous system." As illustrating the handi-
capping which a method is sometimes subjected to, he introduces the report
of a case of ante-partum hemorrhage, under the care of Dr. Braxton-
Hicks, which suggests — what further on he plainly states — that the
fatal result was not due to the transfusion, but to an unwise obstetrical
procedure. In contrast to this he cites a similar case of his own, where a
conservative obstetrical management, combined with transfusion according
to the plan he advocates, was followed by a rapid recovery. In this con-
nection the course of the book is broken to admit a sensible argument in
favour of the conservative treatment of cases of ante-partum hemorrhage,
and by a somewhat intemperate opposition of Dr. Barnes and styptic in-
tra-uterine injections of perchloride of iron.

The next and last chapter discusses the way to execute the operation of
transfusion. Here, again, the difficulties and dangers of immediate trans-
fusion come up and are dwelt upon in detail, and the conclusion, which is
a matter of common experience, announced that this method is far from
being generally feasible. The use of the blood of other species of animals,

1883.] Hoffman, Power, Manual of Chemical Analysis. 235

and of human blood the corpuscles of which have been disorganized, the
author would reject as unsafe. Equally does he object to the employment
of phosphate of soda, as recommended by Dr. Braxton-Hicks, to prevent
fibrination. His preference is strongly in favour of the transfusion of a .
saline solution made as follows : —

Chloride of Sodium . . . ♦ . . . . 50 grains.

Chloride of Potassium ...... 3 "

Sulphate of Sodium . . . . . . . 2.5 "

Carbonate of Sodium ...... 2.5 "

Phosphate of Sodium (Na3P04) . . . . 2

Water (100° Fahr.) . . . . . . 20 ounces.

Alcohol (absolute) ....... 2 drachms.

The apparatus he prefers is a simple siphon with a suitable canula, and
one or two other slight additions to adapt it to its object.

It will be seen from this analysis that our author is a person of positive
convictions and equally positive assertions, while his experience is calcu-
lated to encourage testing the method he recommends. It certainly ap-
pears that the primary advantage of transfusion consists in the supply of a
fluid of proper physical composition to fill the flaccid bloodvessels and give
the heart something to act upon. If the whole volume of blood were lost,
nothing but blood could fitly take its place. But when only a relatively
small proportion has flowed off, a simple saline solution may be of great
service. The author's apparatus also commends itself to the judgment, as
meeting all the indispensable indications, without being of a complexity
which would make mishaps probable.

So much for the matter of this book. The manner, as intimated already,
is in the main attractive. There are some infelicities of expression, some
inconsistencies of wording (as in his formula, which we have harmonized in
quoting it), some abrupt transitions from one part of the subject to another
which might be improved, and the end comes so suddenly that one is sur-
prised, on turning the page, to find that he has reached it. Nevertheless,
as a whole, this monograph is interesting as well as instructive, and it
prompts the hope that the author may continue his study of the subject of
transfusion, and, when the proper time arrives, give the medical public
the result of his increased experience and more mature reflection.

C. W. D.

Art. XXXIII — A Manual of Chemical Analysis as applied to the Ex-
amination of Medicinal Chemicals. A Guide for the Determination of
their Identity and Quality, and for the Detection of Impurities and
Adulterations. For the Use of Pharmacists, Physicians, Druggists,
Manufacturing Chemists, and Pharmaceutical and Medical Students.
Third edition, thoroughly revised and greatly enlarged. By Frederick
Hoffmann, A.M., Ph.D., Public Analyst to the State of New York,
and Frederick B. Power, Ph.D., Professor of Analytical Chemistry
in the Philadelphia College of Pharmacy. 8vo. pp. 624. Philadelphia :
Henry C. Lea's Son & Co., 1883.

The volume before us has been greatly improved since the first edition
was issued ten years ago. The great advances made in chemical science

236

Reviews.

[July

during this time, and the many contributions to our knowledge of better
methods of analysis, necessitated the elimination of much old matter, and
the insertion of many additional processes. The reappearance of this valu-
able manual is timely, following as it does closely upon the publication of
the PharmacopcEia of 1880 ; and the need of a work of this character is
very apparent, because of the introduction for the first time into the Phar-
macopoeia of volumetric tests. It will thus be seen that pharmacists and
physicians who are required to ascertain the purity of the chemicals which
they use, naturally desire a practical guide which will comment upon, and
explain the action of the pharmacopoeial and other tests. The work is
divided into two parts. Part I. treats of Analytical Operations, Reagents,
Test Solutions, a course on Qualitative and Volumetric Analysis, and Al-
kaloids. In Part II. medicinal chemicals are taken up in detail, their
physical properties described, and then their analytical examination for
identity and purity follows. Each article is treated without referring to
others which precede or succeed it, and the illustrations are frequently re-
peated, so that very little back reference is needed. The saving in space
which was secured by the omission of book and journal references, is,
however, in our opinion, not judicious economy in a work of this kind,
as it very frequently happens that the particular information sought by
the reader has, unfortunately, not been selected by the author in his quo-
tation ; the book or journal reference, however, measurably corrects an
omission which must necessarily be unavoidable, as the most exacting
reader cannot expect to find in a manual articles reproduced in toto.
With the additions that have been made to Part II. it will now be found
that the physical and chemical properties of nearly all of the important
chemicals used in medicine are described briefly but sufficiently, witli such
tests for this recognition as are necessary. Methods for the detection of
accidental impurities or intentional adulterations are also given, and these
cannot fail to be of the utmost service to physicians and druggists who are
compelled usually to rely upon the reputation of the commercial houses
that they deal with. In the case of those chemicals which are likely to
be used as poisons, methods are described for their recognition which will
be very useful in judicial investigations. At the end of the volume will
be found tables which give the symbols and atomic weights of the ele-
mentary bodies and thermometric equivalents ; one for the conversion of
metric measures of capacity into United States fluid measures, one for the
conversion of United States fluid measures into metric measures of capacity,
with similar tables for the conversion of metric weights into troy weights,
and vice versa.

That this manual will prove a useful guide to physicians, pharmacists,
manufacturing chemists, pharmaceutical and medical students is but slight
praise. A work of this character is absolutely necessary to those who ex-
pect to keep abreast of the advances made in chemical science, and who
desire to loyally uphold the requirements of the recognized national au-
thority, the Pharmacopoeia of the United States of America (sixth de-
cennial revision). J. P. R.

1883.] Fischer, Naphthalin in Medicine and in Agriculture. 237

Art. XXXIY Das Naphthalin in der Heilkunde and in der Land-

wirthschaft.

Naphthalin in Medicine and in Agriculture. By Dr. Ernst Fischer,
Privatdocent of Surgery in Strassburg. 8vo. pp. 98. Strassburg :
Karl J. Triibner, 1883.

After an account of the derivation and mode of preparation of pure
naphthalin Dr. Fischer gives a history of its earliest use in medicine,
from which we learn that it was first recommended by Rossignon, in
1842, as a substitute for camphor. It was to be compounded with a fatty
excipient and used as a pomade for sprains and contusions, as well as to
destroy insect parasites and parasites of the intestinal canal. In the same
year Dupasquier recommended it as an expectorant in chronic bronchitis,
especially in debilitated old persons. Likewise in 1842, Emery recom-
mended it for the treatment of psoriasis, and these three endorsers led to
a further endorsement, in 1851, by Wood and Bache, in the U. S. Dis-
pensatory. Later Hebra and Kaposi recorded adverse opinions of its
merits in the treatment of skin diseases, while, in 1862, Kleinhans, hav-
ing tried it in chronic eczema, found it less valuable than tar and oil of
cade.

After this, it was taken up by the author and, after experimentation,
strongly recommended as an antiseptic and parasiticide, beginning in the
end of 1881, and continuing until the present time. His experiments
have demonstrated that naphthalin has several advantages over most
other antiseptics. It is innocuous to the higher orders of animals. Its
disagreeable odour can be converted into an agreeable perfume by the
addition of minimal quantities of oil of bergamot. It is absorbed through
the digestive tract to but a slight extent, and most of what is so absorbed
escapes in the urine.

When ordinary, impure naphthalin is applied freely to large wounds,
it is absorbed and darkens the urine in the same way as carbolic tacid,
though in a lower degree ; but without producing any symptoms of poison-
ing. Chemically pure naphthalin does not darken the urine ; nor does it
produce any local irritation, or even discomfort, when applied to the skin.
It does not make crusts with the secretions of wounds, and so does not
favour their retention. It does not irritate wrounds or impair the process
of granulation. The secretions of old ulcers and carcinomas become
cleaner by the use of naphthalin.

This new agent has the merit of being very cheap, and its method of
application calls for no special appliances, as it is to be simply strewn upon
a wound and its bandages. Its purity must, however, be beyond question.

The disadvantages of naphthalin are : its insolubility in water and
albuminoids ; its disagreeable, although harmless odour ; and the fact
that it does not prevent very free secretion from the surface of large
wounds.

The insolubility of naphthalin prevents its use for cleansing and pro-
tecting the hands and instruments of operators, as well as its application
within wounds that are to be closed by suture. Its odour is not, however,
more disagreeable than that of other antiseptics ; and its permitting of
free secretion, the author thinks, is not an important matter.

Dr. Fischer thinks naphthalin especially applicable in cases where the
kidneys are diseased or very susceptible to the action of drugs ; when the

238

Reviews.

[July

skin is irritable, or there is a strong disposition to absorption ; for children ;
for wounds, ulcerations, and so forth, in deep canals, like the vagina and
bowel, where there is a tendency to decomposition of secretions; for
resections; for the removal of tumours; for erysipelatous wounds; and
finally, for the disinfection of hospitals and suppression of vermin. His
experience in the application of naphthalin in minor and major surgery
has been entirely satisfactory. It is noticeable that he advocates, though
with some misgivings, thorough cleanness of instruments as a substitute
for the asepsis which is usually secured in Lister's method, and which the
insolubility of naphthalin debars him from obtaining by its means. His
success with this substitution he would probably dislike to admit to be an
argument against the exclusive value of antiseptics, which is the keystone
of his, as well as of Lister's, faith.

The author carried out a number of experiments to determine the effect
of naphthalin upon minute fungoid growths, and found that they were
materially repressed or killed by an atmosphere saturated with the gas of
naphthalin. When pus and blood were experimented upon the success
was not so great.

The offensiveness of naphthalin to small animal parasites he found to
be of advantage in diminishing the number of these in hospitals. Its
application to skin diseases has not been marked with much success ; nor
has its use in internal diseases achieved any remarkable results.

The second part of Dr. Fischer's monograph treats of the use of naph-
thalin in agriculture. Here are found reports of experiments conducted
under his supervision, or at his suggestion, which indicate that burying
naphthalin near the roots of the vine has some influence in preventing the
ravages of the phylloxera. The evidence of this influence was found in
the vigour and number of rootlets as compared with those of unprotected
vines near by — no statement in regard to fruit bearing is given. The
author cites the opinions of a number of French observers and experi-
menters— most of them opposed to the claims of naphthalin — and endea-
vours to establish his own views. This is done but unsatisfactorily ; and
while an interesting contribution to the literature of the subject, this part
of his essay is far from a conclusive one.

The monograph before us is the outcome of careful and methodical
study, and is creditable to the honesty and industry of its author. Un-
fortunately it does not carry to the mind of the reader the conviction
which is so plainly discoverable on the part of the writer. In the rage
for antiseptics which shall not have the irritant properties of carbolic acid,
the Germans have lately proposed the use of iodoform, turf powder, naph-
thalin and bismuth. There can be no doubt that each has some advan-
tages as a dressing for surgical injuries, but none of them has secured for
itself a position which promises to be permanent. This is the era of trial,
not of judgment, and it is not surprising that what is lauded to-day is
set aside to-morrow. Every honest attempt, however, adds to the evi-
dence upon which the final opinion shall rest; and the author of this
monograph has made a contribution in which a very manifest zeal has not
led to the suppression of a single fact which might be used to combat his
own position. C. W. D.

1883.] Nettleshtp, Students Guide to Diseases of the Eye. 239

Art. XXXV. — Student's Guide to Diseases of the Eye. By Ed.
Xettleship, F.R.C.S., Ophthalmic Surgeon to St. Thomas's Hospital
and to the Hospital for Sick Children. Second American from the
second revised and enlarged English edition. With a chapter on Ex-
amination for Colour Perception, by Wm. Thomson, M.D., Prof, of
Ophthalmology in the Jefferson Medical College. 8vo. pp. 416. Phila-
delphia: H. C. Lea's Son & Co., 1883.

Though the last few years have been fruitful in ophthalmic manuals
to an extent that has been thought to be suggestive of over-production,
the early demand for a second edition of Nettleship's work proves that
it at least has u fulfilled a want." Some changes and additions have been
made which, it is thought, will adapt this edition still better to the needs
of the class of readers for which it is intended. The author is unusually
happy in the difficult task of being always brief and never obscure, and
has produced an excellent epitome of the practical ophthalmic surgery of
the present time. The medical and operative treatment recommended
corresponds very closely to the general practice of ophthalmic hospitals
in this country ; almost the only decided exception is the use of the bar-
barous, and we had supposed obsolete, procedure of putting a seton in the
temple for the relief of ulcer of the cornea and of chronic interstitial
keratitis. This recommendation seems particularly unfortunate in the
case of the latter disease, the cure of which depends so essentially upon
internal medication and time.

The last chapter, on diseases of the eye in relation to general diseases,
will be found particularly interesting and useful to the general prac-
titioner.

The principal additions to the second edition area chapter on " Optical
Outlines," by the author, and one on " The Practical Examination of Rail-
way Employes as to Colour-blindness and Acuteness of Vision," by Dr.
AVm. Thomson. The former gives a very clear exposition of the elements of
optics, the knowledge of which is necessary for the intelligent use of the
ophthalmoscope and the correction of optical errors, and will be very
useful to beginners and to those who cannot spare the time to go more
deeply into the subject.

Dr. Thomson gives the plan that he has adopted for testing the employes
of the Pennsylvania Railroad, and explains the use of his very ingenious
instrument for the examination for colour-blindness. The object of the
latter is to enable intelligent laymen to collect the facts in each case and
record them in such a way that the professional expert can come to a
correct decision without seeing the person examined. The report of 1383
examinations made in this way gives a percentage of colour-blindness fully
up to the average found in examinations made directly by ophthalmic
surgeons ; and if more extended experience should confirm this encour-
aging result there will be hope of a practical solution of a much-discussed
and most important problem.

The illustrations are numerous and most of them unusually good, and
the paper and print are excellent. G. C. H.

240 Reviews. [July

Atct. XXXVI — Sore Throat: its Nature, Varieties, and Treatment;
including the Connections between Affections of the Throat and other
Diseases. By Prosskr James, M.D., Physician to the Hospital for
Diseases of the Throat and Chest. Fourth edition, enlarged, with
coloured plates and wood engravings. 12mo., pp. 318. Philadelphia :
P. Blakiston, Son & Co., 1882.

This appears to be an unchanged reprint or reissue of the same edition
of this work published in 1879, and therefore calling for little additional
comment at this time. Dr. James lias long been known as devoting him-
self to the department of throat diseases; having as long ago as 1859 em-
ployed reflected light for the purpose of applying local medication. His
treatise is divided into three parts : 1. General preliminary sketch of the
whole subject ; 2. Diffused affections, by which he means affections not
limited to any special structure; and 3. Diseases of individual organs.
These subjects are discussed from the standpoint of a large personal ex-
perience, with very little allusion to contemporaneous authorities. His
views are not always in general accord with those of physicians largely
engaged in the same line of practice, and while they will not meet with
the full approbation of his readers, it is of some importance that they
should be carefully considered. We have to deprecate the far, far too fre-
quent use of the pronoun my, an affectation which should be discarded by
all who write in the vernacular. There are several instances in the volume
before us where claims of originality are positively and inferentially made,
which cannot be sustained by recorded evidence. For instance, the claim
is made, and it has even been repeated by some of his English colleagues,
that the use of steam vapour in the treatment of croup and diphtheria
emanated from this author in 1801 ; and he alludes to it as "a recent out-
come of German medicine ;" while it ought to be well known, as a simple
matter of history, that this valuable method received full recognition by
Wanner, whose monograph, Du Croup et de son traitement par le oapeur
d'eau, was published in Paris in 1834. An illustration, and the manner
of allusion to it (p. 66), seem to claim the Mackenzie bracket and lamp;
and so of other things.

Dr. James takes a much more hopeful view of laryngeal phthisis than
the experience of most practitioners would seem to justify. It is .but fair
to him to state that similar prognostications, founded upon personal re-
sults, have been maintained for some time on this side of the Atlantic, by
Professor Bosworth, of New York ; though the latter advocates a special
line of topical medication differing from that of the author.

We had hoped that the wretched coloured illustrations of this book would
have been suppressed long ago. They are simply a disgrace to the text,
to the author, and to the publisher.

In conclusion, we may safely commend the volume as the best of the
smaller hand-books on the subject. J. S. C.

1883.]

241

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AXD DISCOVERIES

IN THE

MEDICAL SCIENCES.

ANATOMY AND PHYSIOLOGY.

Partial Regeneration and New Formation of the Liver.

Tissoni, Professor of Pathology at Boulogne, in making some experiments in
the spleen of a dog, accidentally wounded the liver. Six months afterward, on
examining the wounded organ, he found a tumour at the site of the cut having
all the characteristics of liver tissue. The tumour was prolonged in the form
of a triangular tongue, about §• inch long, about 1\ inch broad, and |- inch
thick at its base, by which it was united to the border of the liver at the site of
the original wound. In its centre was a large vessel with numerous collateral
branches. The new growth was treated with bichromate of potash, hardened
in alcohol, and numerous sections made. From a microscopical study of the
sections Tissoni concludes that: 1. Under certain circumstances the liver may
be reproduced at the wounded point ; there was a new formation of the hepatic
cells and of the biliary ducts in addition to those already existing. 2. Contrary
to what takes place with the spleen, the great omentum adhering to the hepatic
wound takes no part in the new formation of this organ and represents only the
base and stroma in which the new tissue is born and developed. 3. The origin
of the reproduced tissue is found in the pre-existing hepatic cells, which, by
cellular multiplication, send out branches similar to the hepatic cylinders (Leber-
cylinder of Remak) which are observed in the embryonic formation of that
viscus. These branches are infiltrated in the omentum as the prolongations of
an epithelial tumour infiltrate the connective tissue of the skin. The hepatic-
cells present numerous nuclei, which are readily coloured by carmine. 4. The
cellular threads originating from the hepatic elements present, some, a central
lumen, and have the characters of the bile-ducts ; others are small, filled with
protoplasm and nuclei, and have the appearance of hepatic cells. 5. The new-
liver cells, which are histologically similar to the old, are similar to the embryonic
liver ceils from which they are for some time separated by true blood-lacunae.
8. The acinous arrangement is wanting, but the large bloodvessels, especially
the veins, and large bile-ducts are seen. From this it maybe concluded that the
regeneration of the liver is in every way identical to its embryonic development:
described by Remak and Kolliker. — Journ. de M6d. d& Paris, April 28,, 1883,
No. CLXXL— July 1883. 16

242

Progress of the Medical Sciences.

[July

A New Crystalline and Coloured Body in the Urine.
Ploz (Zeits. f.physiolog. chemie, Band vi. p. 505, 1882) has recorded the
following which is of especial interest : A patient with pyelitis and chronic
parenchymatous nephritis, presented in the sediment of the urine a crystallized
and coloured material, bearing no analogy to any known substance. For some
time the patient passed urine which was decomposed, alkaline, giving the am-
monia and sulphuretted hydrogen reactions, very cloudy, with a sp. gr. of 1014.
Microscopic examination showed pus-corpuscles, a few blood-disks, epithelial
cells, and cylinders of various kinds, crystals of ainmonio-magnesian phosphates,
and a crystallized deposit of indigo-blue colour. On exposure to the air the sur-
face of the urine took a greenish-brown colour, which disappeared when kept for
some time in a closed vessel. On exposure to the air in a thin layer, the surface
of the urine took a greenish-brown colour, passing to a permanent red. Micro-
scopic examination showed that the quantity of indigo was increased, and that
there also existed another crystallized substance of a violet-red colour, very dis-
tinct from the indigo crystals, forming needle-like bundles and rhombic tables. It
was obtained by acidulating the urine with hydrochloric acid, then shaking in the
presence of air in thin layers ; then letting it stand for eight or ten hours until
completely coloured ; it was shaken up with alcohol or ether, which dissolved out
the colouring matter with a trace of indigo, the presence of the latter being de-
termined by spectrum analysis. The solution of this new substance in chloroform
or ether presented characteristic absorption bands — one between D. and E.,
nearer to D., and two others between J. and F., nearer F. These bands differed
completely from those of indigo, the bands of which were not seen. A solution
of the substance in chloroform was neither affected by the presence of air, by
boiling, nor by the action of acids or alkalies. On evaporation the solution left
a few traces of indigo and red crystals. The patient died eight days after coming
under observation, having taken no medicine. Ploz remarks that this substance
has neither the characteristics of uro-erythrine nor uro-rubrohematin, and he is
inclined to consider it as a new substance. — Revue des Sciences J\J6dicales,
April, 1883.

Urine Ferments and Fermentation.

Bechamp, in a paper on this subject, draws the following conclusions: 1.
Atmospheric germs cannot enter the bladder by the urethra ; this is anatomically
impossible. 2. Even supposing that ferment germs enter the bladder during
catheterization, they are not the cause of ammoniacal fermentation. 3. Though
the existence of atmospheric microzymes and their tendency to evolute into bac-
terias may be affirmed, it is certain that the}' are not the immediate cause of am-
moniacal fermentation of the urine. 4. Bacteria may exist in the urine or in
the bladder without ammoniacal fermentation taking place. 5. When urine be-
comes ammoniacal in the bladder the phenomenon is due to some morbid state
of the urinary apparatus or to a diabetic state. 6. The fact that urine may be
ammoniacal in the bladder, and that that state is due to the presence of infusoria,
demonstrates that there is a functional difference between microzymes in the
normal state and microzymes very similar to those of fermentation, which have
become morbid on account of some lesion of the urinary apparatus or to some
general diseased state. 7. The zymosis which causes fermentation of the urea
is the result of morbid alterations of the function of the microzymes, for every
soluble ferment is secreted by some organized substance, cell, or microzyme. 8.
The ferments of ammoniacal fermentation may cause sugar and fecule fermenta-
tion. 9. There is an acid fermentation of urine, and the ferments of that fer-

1883.]

Materia Medica and Therapeutics.

243

mentation are similar to those of ammoniacal fermentation. These5ferments also
act on starch and cane sugar. 10. One can always, with the aid of carbolic acid
or creasote, stop the evolution of microzymes in normal urine and its ammoni-
acal fermentation. — Bull, de V Acad, de M<?d., 2me serie, t. x.

Hemorrhage by Vaso-motor Irritation.
M. Brown-Sequard has observed hemorrhages under the occipito-atloid mem-
brane and in the cavity of the fourth ventricle in birds whose neck had been cut
off at the level of the fifth or sixth cervical vertebra. These hemorrhages did
not result from the effusion of blood from the section and reascending toward the
cervical region, for the intermediate space contained no effusion. He thinks that
these hemorrhages are similar to those seen in different organs following lesion of
the upper part of the cord, and refers them to a vaso-motor irritation produced
by lesion of the central nervous system, and is inclined to explain them by this
mechanism ; the vaso-motor irritation producing at once energetic constriction of
the arteries and veins, determines also a forcible projection of blood into the
capillaries, the walls of which yield to the excess of internal pressure. — Gazette
Hebdom., April 20, 1883.

MATERIA MEDICA AND THERAPEUTICS.

Physiological Effects of Cinchonidine.
MM. G. S^e and Bociiefontatne have made a series of physiological exper-
iments with a sample of cinchonidine, the purity of which was proved by Oesch-
ner and Coninck.

Toxic Properties. — Frogs succumbed to gr. \ of sulphate of cinchonidine in-
troduced subcutaneously ; dogs to 9 ij given in the same manner. Pigeons and
rabbits were not so much affected.

Physiological Effects. — These were in accordance with those noted by Raffes-
tie (1876), Weddell (1877), and Cerna (1879). They were similar to the
effects of quinine and cinchonine, the convulsions and salivation of the last being
more pronounced in the dog, just as the vomiting from cinchonidine is more
noticeable in that animal. None of these agents produced convulsions in the
frog, and they are frequently absent in rabbits and dogs, and are only produced
by toxic doses ; consequently none of them can be classed without restriction as
convulsive agents, such as strychnia ; their place is rather among the substances
which depress the central nervous system after momentarily exciting the circula-
tion. It may be remarked that on man, in the normal state (the experiments
being made on one of the authors of the memoir), sulphate of cinchonidine pro-
duces acceleration of pulse, increased surface heat, etc. ; that is to say, a collec-
tion of symptoms which is ordinarily combated therapeutically by sulphate of
quinine. — Gazette Hebdom., April 20, 1883.

Physiological Action of Veratrine.

MM. Pecholier and Redier, after a series of experiments on frogs, rabbits,
and dogs, draw the following conclusions as to the action of veratrine : —

1. Local action.* — It has a topical irritating effect on the skin and mucous
membranes, which is augmented when the derma is removed. 2. Digestive

244

Progress of the Medical Sciences.

[July

tract, — Veratrine is a powerful emeto-eathartic, producing abundant vomiting
and copious stools. 3. Secretions. — Hypersecretion of nasal mucus, sialorrhoea,
moderate diuresis, diaphoresis rarely. 4. Circulation. — (1) Primitive accelera-
tion due in great part to the vomiting. (2) Secondary slowing of the heart's
action., which may terminate in collapse. Heart stops in diastole. Alteration of
the blood. In the frog, arrest of the lymphatic hearts before the blood-heart.
5 Action on respiration. — (1) Primitive acceleration. (2) Secondary slowing :
painful and difficult respiration. 6. Temperature. — Lowering clearly determined
by the thermometer. 7. Muscular system. — (1) Primitive excitation more or
]ess short, according to the intensity of the dose, with apparant contractions. (2)
Subsequent weakening and paralysis. Clear antagonism by strychnine, in spite
of the opposite opinions of many authors. (3) Complete paresis and collapse.
8. Nervous system. — (1) Nervous motility not affected: the primitive excita-
bility of the muscular tissue is determined by the contact of the veratrinized
blood on the muscular fibre and not by the action of the motor nerve affected by
the veratrine. This substance, Kolliker to the contrary notwithstanding, has no
direct action on the cord. (2) Sensibility ; to the irritating topical action, already
mentioned, succeeds anaesthesia and analgesia. The intellectual functions are
not impaired. — Gaz. Hebdom., April 27, 1883.

Eucalyptus Steam in Infectious Diseases
Mr. J. Murray Gjbbks, of New Plymouth, N. Z., has presented an interest-
ing note of his experience with this treatment, which consists in keeping the
patient in an atmosphere of blue-gum (Eucalyptus globulus) steam. It is an
acknowledged fact that in blue-gum we have a most perfect disinfectant; not an
artificial one, but one of nature's own; one always at hand, for it will grow in
temperate climates. The green leaves hung in a bedroom keep it sweet; leaves
placed on a wound, steam inhaled from it, or its infusion drank, or injected, into
wounds, all answer equally well. Professor Lister speaks highly of the eucalyptus
oil for wounds, and it is also spoken highly of in rheumatism. It has not an
unpleasant smell, and is tolerated by nearly all. By infectious diseases, he means
those which are caused by micro-organisms.

His experience with this disinfected steam was in an epidemic of diphtheria
near New Plymouth in October, 1882. Thirty-seven cases in which the treat-
ment was carried out recovered without a bad symptom, such as paralysis, with-
out any medicine except castor-oil, and without stimulants, which disproves the
statement that diphtheria requires a large quantity of alcohol. The disinfectant
he used was made by pouring boiling water on blue-gum leaves. The patients
were kept in the moist atmosphere for some days. He mopped the throat with
dilute solution of perchloride of iron and glycerine every eight hours, and then
covered the pharynx with powdered sulphur. This was done in most cases, but
the others recovered equally well. Two young ladies, aged seventeen and nine-
teen, coughed up complete casts of the large bronchi. An old lady, after he had
mopped her throat once, refused to have it done ; she had a very dense patch
behind and on the right tonsil, the glands of her neck were very swollen and
tender, the neck enlarged, and the breath was most offensive. On the third day
half of the membrane had come away in small pieces, like grains of rice, the
breath was sweet, and the swelling of the neck had nearly disappeared, and she
made a perfect recovery. The epidemic was an unusually severe one, judged by
the number of deaths of those who were treated by other means. The last cases
which occurred took place in two families closely allied, five children and their
nurse being attacked. He attended two of the children (the first and last attacked)

1883.]

Materia Medica and Therapeutic

245

and the nurse. They recovered, whilst the other three, who were attended by a
colleague, died. Local remedies are very good, but they are only a part of the
treatment. We cannot perpetually keep spray applied to the throat, the children
moving about from side to side of the bed. We must take the cure to them, and
we can only do this by means of steam. His mode of procedure is very simple.
He pours boiling water on blue-gum leaves, in a tub, jug, or chamber, which he
places beside the bed, and changes it every half hour. If only one child is ill in
the room he improvises a tent over the bed, either by means of an open umbrella
with a sheet above it, or by placing a sheet over the sides or ends of the bed, and
incloses the patient. It is wonderful to see how soon the pain in the throat and
the swelling disappear, and the fever also.

At first he used a simple fever mixture ; but he found it was not needed, as
the skin acted more or less according to the amount of steam used. The patients
were able to eat bread and batter, the throat not being sore because he had not
burnt it. In diphtheria the throat is never very sore unless caustics are applied.
In simple cases of it many remedies will answer ; but if it once gets to the larynx
and below it no remedy can touch it except steam. The laryngoscope showed
patches on the vocal cords, and the breathing that it had extended lower; and in
some cases where suffocation seemed imminent the distressing symptoms would
be suddenly relieved by the membrane being coughed up.

Although blue-gum steam has answered so well with him, it is not the remedy
alone that he wishes to bring before the profession, but the principle of the
treatment, feeling sure that when a thorough trial has been given to it no other
treatment would be found to give such satisfactory results ; and if it answers in
diphtheria it would answer equally well in other infectious diseases. In typhoid
fever the heat would be lessened, the skin kept moist, and the bowels would not
have to do double duty. In pertussis it would allay the irritation of the bronchial
mucous membrane in the same way that it does in bronchitis, croup, and asthma.
In scarlatina the congestion of the pharynx and the skin would be relieved. In
so-called laryngeal phthisis it has given most satisfactory results. In influenza
the infusion of Eucalyptus globulus is a very popular remedy, and it is one of
the most infectious diseases. If blue-gum steam were adopted as a disinfectant,
or any other drug, in the ward of a hospital, he recommends a boiler outside, with
pipes leading into the ward along the floor, with small holes in them to allow the
steam to pass through, and have a stopcock at the commencement to regulate the
amount of steam. A pipe could also be placed along the wall, with mouth-pieces
attached, for those patients who suffered from throat affections. The boiler could
be placed in a sand-bath, so as to regulate the heat of the water, or a gas-stove
used. The leaves could be placed in a net in the water, and changed as often as
required. The advantages of the blue-gum steam treatment are that it can be
used by ordinary attendants ; in fact, a farmer at Tikorangi treated seven cases
and cured them. In one of these cases, the membrane returned again and again
for three weeks. He trusted entirely to the blue-gum steam. No internal
remedies are required.

The method of employing eucalyptus leaves is inapplicable where they cannot
be obtained fresh in any quantity. The difficulty can, however, be effectually
surmounted by saturating the air with the vapour of eucalyptol, as is done by the
machine invented by Mr. A. W. Mayo Robson and described in the Brit. Med.
Journal for September 2, 1882. The nurse, or other attendant, is directed to
work the bellows for a few minutes, at occasional intervals, so as to keep the air
of the room odorous of eucalyptol. By converting the air of the sick chamber
into a pure and antiseptic atmosphere, it refreshes and soothes the patient; and in
rooms occupied by consumptive cases the antiseptic treatment may be effectually

246

Progress of the Medical Sciences.

[July

carried out without muzzling the invalid by a respirator. In bedrooms occupied
by fever or other infectious cases, the eucalyptus air is not only advantageous to
the patient, but salutary to the attendants, since it effects more than is accom-
plished by the usual disinfectants, by attacking the germs of disease as they are
diffused in the air. — Lancet, Feb. 24, and Mar. 31, 1883.

Therapeutic Use of Nitro- glycerine.

Dr. Henri Huciiard discusses the therapy of nitro-glycerine in a paper,
from which the following general conclusions may be drawn : —

Nitro-glycerine is a vaso-motor paralyzer, and as such may be of service in :
1. Diseases of the heart, and especially those of the aorta, in which cases it com-
bats the symptoms of cerebral anaemia, as Dujardin-Beaumetz has shown to be
the case with nitrite of amyl. In these affections the danger is not so much from
the heart as from the brain. Nitro-glycerine may be advantageously adminis-
tered in cases of aortic affections with predominance of cerebral ischsemia. In
cardiac affections characterized by a feeble state of the myocardium, amyl nitrite
has been regarded as a cardiac stimulant, and nitro-glycerine has, doubtless, the
same action. Nitro- glycerine has been especially productive of good results in
angina pectoris, in doses of three drops a day of a solution of 1-100. It has also
been successfully used in patients having a tendency to syncope, palpitations,
etc., but only in those cases in which there is a nervous or anaemic state.

In nervous affections with cerebral anaemia, and in vascular neuroses, such as
migraine, angiotonic migraine especially, non-congestive facial neuralgia, notably
in that of anaemia, and in cephalalgia of the same order, nitro-glycerine has
given excellent results. Hammond and Green have recommended its use in con-
vulsive affections, as epilepsy and puerperal convulsions. It has been used with
some success in cases of neurasthenia and in those of functional cerebral ischaemia,
and would seem to be of service in certain cases of mental alienation. Schramm
has used nitrite of amyl advantageously in cases of melancholia.

Since nitro-glycerine is a dilator of the peripheral vessels, it may be recom-
mended in local syncope or asphyxia of the extremities, often occurring in hys-
terical subjects. In anaemic vertigo and Meniere's disease it has given excellent
results. Since it determines polyuria and diminished arterial tension, it would
seem to be indicated in chronic and interstitial nephritis, and Robeson has re-
ported two cases in which it produced free diuresis, with diminution of the albu-
men, though Huchard has not had the same good results. The formula used by
him is: distilled water, f^x; solution of nitro-glycerine, 1-100 gtt. xxx ; dose,
three teaspoonfuls a day, one after each meal. It is clearly contraindicated in
all cases in which there is a tendency to congestion, especially to cerebral con-
gestion.— Bulletin Gen. de Therap., April, 1883.

Subcutaneous Injections of Stimulants.

Dr. W. Zuelzer has used stimulants subcutaneously for some years, having
published a paper on the subject in 1871 in Berliner Klin. Wochensch., No. 81.
Those which have come into use since that time are ether, camphorated oil (1 in
10) ; camphor and benzoic acid (camphor 1 part, benzoic acid 1^-, rectified
spirit 1 2) ; ethereal solution of camphor (sulphuric ether saturated with camphor) ;
liquor ammoniae anisatus ; valerianate and some other preparations of ammonia :
spirit of sulphuric ether; tincture of musk (1 part of musk to 25 each of water
and dilute spirit) ; cognac, and several ethereal oils.

None of the remedies employed have caused any bad general effects, and their

1883.]

Materia Medica and Therapeutics.

247

action on respiration and circulation has been nearly alike in all — viz., immediate
strengthening of both ; but as they have generally to be repeated several times
within a short space of time, it is important to avoid those which are irritating —
e. g., the preparations of ammonia, and still more alcohol, which easily produces
sloughing of the skin. Camphorated oil causes the least pain, but is inconvenient
on account of the small quantity of camphor held in solution — a large quantity of
oil having the effect of retarding the respiration. Caffeine is useful where small
doses only are required, on account of it being sparingly soluble (1 in 80). It
may be injected into the arm of the affected side in migraine. Large doses cause
irregularity of the heart's action, dizziness and faintness in healthy individuals.
Ether and the ethereal solution of camphor have the disadvantage of partially
dissolving the shellac with which the end of the hypodermic syringe is fixed to
the cylinder. The author has therefore had a special syringe made for him by
Goldsmidt of Berlin, of which the entire upper part is of glass ; the cylinder end-
ing in a glass cone, well ground in order to afford a proper hold for the needle.
The pestle is of leather, firmly bound round with yarn, and graduated for the
measurement of small quantities. The whole syringe is larger than usual, and
will contain 4 to 5 centimetres (68 to 85 minims) of ether. Both ether and the
ethereal solution of camphor can be employed freely, as no undesirable results
have been known to follow their use even in large doses ; partly, no doubt, be-
cause they immediately pass off by the breath. The pain after their injection is
not great, lasts sometimes for several hours, and leaves behind it some numbness
of the part. One cubic centimetre (17 minims) of pure ether may be injected
into each of the four extremities at one time, and may be repeated in fifteen
minutes at first, afterward at longer intervals.

The most important indication for the use of these remedies is collapse, when
the patient is unable to swallow, or where a more rapid result is desired than by
the stomach. The author has employed them most often in enteric fever and in
cholera. When, in typhoid fever, there are great cardiac debility, small and
irregular pulse, cyanosis, and coldness of the extremities, with deep collapse, the
injection renders the pulse fuller and stronger within a few minutes; the cardiac
contractions become more energetic, and the cyanosis disappears after one or two
injections. Where the urine has been suppressed, diuresis follows their use, and
Lindwurm states that the vomiting of enteric fever is arrested, a fact which the
author has observed in Asiatic cholera. Leube, in Ziemssen's Handbuch, recom-
mends their use in the dangerous swooning after gastric and intestinal hemorrhage,
where there is the advantage of introducing the remedy into the system without
involving the affected organ. Jlirgensen, in the same publication, recommends
camphorated oil in pneumonia, when weakness of the heart supervenes ; and ether
has been found of great service in oedema of the lungs in the same disease. Gelle
relates a case of convulsions, coma, and vomiting, in a child of 1\ months, where,
after the injection into each thigh of 10 minims of ether, the symptoms disap-
peared, and the pneumonia of which they were the prodromata, although severe,
was recovered from.

The subcutaneous use of stimulants in midwifery also is extending, Bayr de-
scribes nine cases in Hecker's clinic, seven of acute anaemia, one of shock after a
difficult labour, and one of unfavourable anaesthesia, treated in this way. Five
improved suddenly, the others gradually. Von Hecker has injected as much as
10 grammes (2|- drachms) without either local or general disturbance, and he con-
siders that the temporary irritation caused by the ether is especially beneficial in
anaemic individuals. Winckel uses alternately ether and amorphous hydrochlo-
rate of quinia, each three or four times in one day. After quoting a case given
by Macan Dr. Zuelzer goes on to recommend the treatment specially in de-

248

Progress of the Medical Sciences.

[July

liveries under chloroform, and in hemorrhages, either post partum or from pla-
centa prasvia, as employed by Chantreuil.

Liquor ammonias anisatus has been injected in a case of morphia-poisoning
related by Levinstein ; and ether injections proved serviceable in collapse follow-
ing a suicidal dose of chloral-hydrate, 10 grammes (154^ grains). Finally,
subcutaneous injection of ether has been employed with success in dropsy from
fatty heart, where it increases, at least temporarily, the renal secretion. — Land.
Med. Record, May 15, 1883; from Deutsche Medicin. Wuchensch., Feb. 28,
1883.

Bismuth Treatment of Wounds.

The use of bismuth in antiseptic surgery has yielded good results in Germany,
especially in the hands of Kocher, of Bern, who has used it more extensively
than any other surgeon. From experiments made by Schuler, Kocher's student,
he concluded that the antiseptic qualities of bismuth were due to its preventing
the development of micro-organisms of putrefaction, and Kocher has shown that,
in the treatment of wounds, less depends upon disinfection — annihilation of micro-
organisms, than upon antisepsis — preventing the development of the bacteria.

In view of the ill elfects sometimes following its use, it is better not to apply
the bismuth in the form of powder in unlimited quantities. One per cent, of
bismuth suspended in water has fulfilled all the requirements of thorough anti-
sepsis. Owing to the insolubility of bismuth, it should be most thoroughly tritu-
rated in water in order that no grittiness should be present, and the emulsion thus
formed should be shaken until the salt is equally diffused throughout the fluid
before using. Kocher applies it in the following manner: From an ordinary
squirting bottle the wound surface is moistened at intervals in the course of an
operation, so that the loose cellular tissues in particular are covered by a thin
film of bismuth ; at each dressing this procedure is repeated, but when the edges
of the wound have been brought into apposition, bismuth, made into a thick paste,
is spread up on the line of suture and allowed to dry into a crust. This method
has been followed by the happiest results. The dressings of Kocher then con-
sist of (1) strips of absorptive material covered by (2) a layer of gauze — both of
these having been dipped in a ten per cent, solution of bismuth, and the mois-
ture thoroughly wrung out before application — and over these is laid (3) a piece
of India rubber cloth, (4) cotton wadding, and (5) a dry roller bandage finishes
the dressing.

Having in view the fact that, with favourable external surroundings, the open
treatment of wounds is not inferior to the antiseptic method, he adopted a plan
which he calls the "secondary suture" in which he claims to have retained all
the advantages of the open treatment without interfering with the success of anti-
septic methods. In all cases where it did not seem advisable to rapidly complete
the dressing, as after a prolonged operation or because of the exhausted condi-
tion of the patient, the sutures were not tied, but bismuth was applied in various
ways. If hemorrhage was present, bismuth-gauze was introduced into the wound ;
when, however, hemorrhage had ceased, the bismuth dressing was applied only to
the surface, the edges of the wound having been brought into contact. After
twenty-four or even twelve hours, but when secondary hemorrhage had super-
vened, after thirty-six or forty-eight hours, the wound was finally closed by the
sutures, no opening being allowed to remain. For this "secondary suture," cat-
gut can be used because of its weakness, and strong silk thread should be pro-
vided, since, because of the plastic swelling of the lips of the wound, some force
is required to bring them into apposition — especially when the wound has been
permitted to gape. The secondary suture was employed in a number of opera-

1883.]

Materia Medica and Therapeutics.

249

tions of widely varying character and situation, and, as a result of this experience,
Kocher asserts boldly that the formation of wound secretion after twelve to
twenty-four hours is not a necessary consequence of simple traumatism.

Bismuth possesses, to an eminent degree, the property of reducing the amount
of wound secretions ; it has long been successfully used as an astringent in case
of abnormal secretions of the intestinal canal. In its desiccating and astringent
qualities are found a considerable part of its value. It is, therefore, of double
value in the treatment of wounds in that (1) it secures perfect asepsis of the sur-
face, and (2) it limits secretions in the cavity of the wound.

To obtain the advantage which bismuth offers for securing union by first inten-
tion, certain other points must receive attention. The collection of a quantity
of blood in the cavity of the wound must be prevented. This may be obtained
by the forcipressure forceps of Pean, Billroth, or by Kocher's modification of the
latter. The advantages of these forceps consist in the fact that they grasp firmly
when applied, take up a limited amount of space, and are absolutely aseptic.
Hemorrhage, therefore, can be promptly controlled. Since extravasation from
blood and lymph vessels cannot be absolutely prevented by ligature, a uniform
compression of the edges and surface of the wound throughout its whole extent
is necessary.

In cases where the great irregularity of the wound cavity and the surrounding
conditions did not admit of the application of sufficient pressure, the secondary
suture was substituted.

In Kocher's experience with bismuth, usually within twenty-four hours, but
varying from twelve to thirty-six hours, secretion from the cavity of the wound
ceased. Small superficial granulations along the lines of sutures sometimes de-
layed healing for days ; these are simply treated by the application of bismuth
paste, when healing by scab will ensue.

With the rapid healing of wounds following the use of these methods, care
must be taken against too early exertions upon the part of patients, subjecting
them to the possible detachment of emboli, from imperfectly organized thrombi
in the severed vessels. Experience shows that there is particular danger of this
in wounds of the neck and other parts where the ligature of a large vein may
have been necessary.

The perfect asepsis secured by bismuth is the chief point in its favour. For
instance, in a case of knee-joint disease with fungous degeneration, where the
joint was opened and the diseased tissue removed, then dressed with bismuth and
the secondary suture, without the use of drainage-tubes, rapid and uncomplicated
recovery ensued.

Another advantage of bismuth, if used according to this method, is the entire
absence of direct systemic effects. The great simplicity of the method, and the
absence of cumbersome details and apparatus, is of great advantage to the sur-
geon. The convenience and freedom from annoyance to the patient as well is
greatly in its favour. The application of the salt upon a fresh wound surface
causes, momentarily, a smart burning sensation. On the second clay, when the
secondary suture is applied, the patient no longer complains when the bismuth
irrigation is used.

As an antiseptic, bismuth is of greater use than iodoform on account of its in-
solubility. If it is desired to disinfect hands or instruments, or if an infected
wound and the integument surrounding it must be disinfected, i. e., if pathogenic
organisms, which have found entrance to the wound, are to be destroyed, soluble
antiseptics, like carbolic acid or corrosive sublimate, should be used. — Annals of
Anatomy and Surgery, June, 1883.

250

Progress of the Medical Sciences.

Bismuth Treatment of Wounds.

Dr. Riedel, of Aix, read a paper before the Twelfth Congress of the German
Surgical Association on the bismuth treatment of wounds in the hospital at Aix-
la-Chapelle, during January, February, and March, 1883. His results with this
treatment corresponded very nearly with those of Kooher. He had been careful
to follow the directions of the latter, except that he omitted the secondary suture,
but had used the primary suture and drainage. The bismuth dressing had given
good results both in fresh wounds and operations and in those in which suppura-
tion had occurred. Though he thought that bismuth was a good antiseptic, yet
it was not an unfailing one. In sixty-one cases in which it was used there were
four phlegmons and eight cases of erysipelas. Even with a combination of bis-
muth and corrosive sublimate there was one case of erysipelas in a patient who
had a putrid compound fracture of the humerus. The beneficial results of the
bismuth seemed to be due to its dryness and its power of suppressing secretions.
He had seen no symptoms of poisoning from the use of it.

In the discussion on this paper, Kocher said that a continued use of bismuth
had increased his confidence in it as a dressing, and he thought that it promoted
union by first intention. Dr. von Langenbeck had had but little experience
in this treatment since leaving Berlin. When he used it lie had closed the wound
immediately and inserted a drainage-tube, which he removed by the end of the
second day. He would fear to fill a cavity with bismuth for fear of poisoning.
As compai-ed with iodoform it had the disadvantage of never forming a scab. He
referred to a case in which he had extirpated an angioma from the inner side of
the thigh. The resulting wound was a large hole, the walls formed of muscles
which moved with every change in the position of the body, and which seemed
very unfavourable for union by first intention. The wound was sprinkled with
water in which bismuth was suspended, a drainage-tube was put in, the edges
nicely brought together, and the whole covered with a bismuth compress. The
drainage-tube was removed on the second day, and the wound healed by first
intention. Dr. Israel had used bismuth after extirpation of a carcinomatous
breast and regretted it. Though the wound healed in ten days, gangrenous
stomatitis was developed, which lasted for eight weeks. Lately the patient had
come back to be treated for numerous nodules about the size of a cherry in the
vicinity of the cicatrix. Incisions showed them to be small collections of bis-
muth.— Deutsche Med. Wodi., Nos. 16 and 17, 1883.

MEDICINE.

Erythematous Eruption in Enteric Fever.

At the meeting of the Clinical Society of London on April 13, 1883, Dr.
Whipham related the particulars of two cases lately under his care in St.
George's Hospital, in which an eruption resembling that of scarlatina occurred.
The first was in a cabman, aged thirty-six, who had been addicted to drink, but
who for twelve months previously to his admission had been a teetotaler. The
fever symptoms had commenced fourteen days before, but the bowels had been
regular and the motions natural. On admission the man complained of sore
throat and headache, and had a bright erythematous eruption on the trunk, legs,
and arms. The right tonsil was much swollen. His tongue was thickly coated,

1883.]

Medicine.

251

his pulse 128, and his temperature nearly 105°. Next day -the eruption was
more marked on the arms and legs, and had extended to the feet. On the third
day after admission the patient became very restless and delirious, and the
bowels, which had been up to this date obstinately constipated, were opened
freely by a purge. The diarrhoea thus set up, though somewhat moderated
towards the last, continued more or less up to the time of the man's death, i.e.,
four days after his admission. No typhoid eruption was present. At the autopsy
extensive ulceration of Peyer's patches was found. The second case was that
of a child, aged four, who was received into hospital on October 6, 1882. He
had already suffered from scarlatina, measles, and whooping-cough. Feverish
symptoms manifested themselves on the day before his admission, and when he
came under observation his temperature was 104.2°, pulse 120. His tongue was
red at the tip and edges, and the papillae protruded from a central white coat.
On the day after his admission a red eruption was noticed on the child's legs,
and he was therefore isolated. Next day the erythema had greatly extended,
and was very brilliant. The tonsils were red and swollen. The bowels were
constipated. On October 10 (four days after admission) the eruption had faded
considerably. The bowels remained inactive, and a purge of Carlsbad salt was
administered, which acted freely. On the 11th the red eruption had disappeared.
On the 13th the temperature reached 105°, and the pulse 132. The child was
delirious and had fits of screaming. The bowels acted once after castor oil, the
motion being partly formed, and of a clay colour. On October 17 characteristic
spots of enteric fever appeared, but there never was desquamation at any time.
From this date the symptoms were clearly those of enteric fever, and the child
died on the nineteenth day after admission. The post-mortem examination re-
vealed extensive ulceration of Peyer's patches and great swelling of the mesen-
teric glands. Dr. John Harley, in Medico-Chirurgical Transactions, vol.
lv., gives twenty-eight cases in which scarlatina was accompanied by swelling of
Peyer's patches, but in only two of which ulceration was found, and also a second
series of six cases in which scarlatina preceded enteric fever, and further narrates
three cases of " mixed scarlet and enteric fever." He also quotes two similar
cases recorded by M. Forget. Dr. Murchison says that in many cases of enteric
fever the characteristic eruption is preceded by a delicate scarlet rash, and adds
that "this is not peculiar to enteric fever, but occurs in other forms of pyrexia."
Sir W. Jenner, speaking of a red rash in enteric fever, says that the disease was
mistaken for scarlatina. Dr. Whipham had lately seen a case of variola which
was preceded by erythema of the abdomen and thighs. The question is, Are
these really cases of double poisoning, of mixed scarlet and enteric fevers ? The
absence of desquamation, and the fact that an erythematous eruption is not un-
common in variola, pyaemia, and other forms of pyrexia, led to the conclusion
that they are really instances of enteric fever preceded by erythema, and not
mixed cases of scarlatina and enteric fever.

Dr. Andrew Clark asked what explanation could be given of the increased
rate of breathing, and what was the probable cause of death in the cases described.

Dr. Mahomed said that he had seen roseolous eruptions precede several cases
of typhoid fever. In the majority of these instances there was a subsequent
desquamation of a trivial character. As an exception, however, he, had met
with a case of enteric fever in which the desquamation was almost as perfect and
as free as in a typical instance of scarlet fever. He was in the habit of speaking
of four rashes which occurred during the progress of typhoid fever — roseola, rose
spots, taches bleudtres, and miliaria. Similar red rashes had been observed to
precede nearly all forms of specific fever. Their occurrence was well known in
cholera and variola ; they had been observed occasionally in typhus.

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Dr. Cavafy thought that rashes of an aspect quite similar to those of scar-
latina possessed a very wide range of occurrence. There were the various rashes
produced by drugs of different kinds, also those found in association with slight
surgical fever, puerperal fever, menstruation. It must be regarded as probable
that in all these instances there was some common bond of connection ; this was
probably an irritation of the nervous system either by direct traumatic influence
or through the blood. In scarlatina he supposed there was paralysis of the vaso-
motor centre due to the action of the poison. In the traumatic eruptions there
was immediate irritation of a peripheral nerve. He related an outline of a case
that he had communicated to the Clinical Society, in which salicylate of soda
seemed to have called forth a remarkable group of symptoms : sore-throat, scar-
latiniform rash on thorax, circumscribed erythemata on backs of hands and ex-
tensor surfaces of forearms. The rash faded in a day, and the erythemata passed
on to the formation of herpetic vesicles. Finally there was desquamation of the
arms, indistinguishable from that occurring after scarlet fever. The ingestion of
quinine has been known to be followed by the development of a scarlatiniform
rash. Surveying the subject generally, it would, perhaps, be best to regard the
matter as still in abeyance. At all events, he knew of no certain means by which
to distinguish such erythemata from true scarlet-fever rash.

Dr. Andrkw Clark quite agreed with Dr. Cavafy that the nervous system was
operative in the production of the erythemata in question. On examination of
the chest of nervous females a diffuse red injection was seen in about seven out
of ten cases, especially when the observation was made in front of the window
with plenty of light. He was in the habit of recording the< various forms which
this erythema assumed, and thought that an explanation must be sought in the
temperaments and habits of the patients. He was familiar with the presence
of the scarlatiniform rash appearing in the actual course of typhoid fever, and
had, rightly or wrongly, attributed these to a special affection of the nervous
system. He had seen them most frequently in anomalous cases in which the
nervous system was specially involved.

Dr. Broadbf.nt was well acquainted with the delicate erythema which so
frequently ran before typhoid fever, but he certainly would never confound this
with a true scarlet-fever rash. When a well-marked scarlatinal rash came out
in any part of the course of enteric fever he always regarded it as evidence of a
concurrence of the two separate diseases. He had seen all forms of combination
between scarlatina and enteric fever. Dr. Mahomed had recited one case this
evening, and he assuredly regarded Dr. Whipham's first case in the same light.
He had lately shown at the Harveian Society a man of weak constitution with
decided loss of tone, in whom an erythematous eruption, not at all unlike a
syphilitic roseola, appeared every time the patient was stripped. There was in
addition a marked tache cergbrale, and the muscular irritability was highly
marked, each tap causing a well-developed local contraction.

Dr. Andrew Clark added that the erythema medicorum, or doctor's rash, of
which he had spoken, sometimes lasted thirty-six hours.

Mr. Herbert Page stated that Hebra had described the cutaneous eruptions as
preceding many acute specific diseases, and especially smallpox. Mr. Page had
seen an acute papular eruption occupy a large surface of the body and fade away
prior to the appearance of an abundant confluent rash on the face of a severe
case of smallpox, in which the patient died about the ninth day. He also
mentioned a somewhat similar antecedent which happened in one of his own
children.

Dr. Whipham, in reply, said that he had brought the cases forward rather
with ' the view of eliciting the opinions of members as to what was the proper

1883.]

M e d i c i n e .

253

course to be adopted. He thought Dr. Cavafy's suggestion to,isolate the patient
in a separation-ward was the right proceeding. He rather came to the conclusion
that his second case was not scarlatina, because the brilliant red eruption had
not been followed in nineteen days by desquamation. He had nothing to say
against the view that scarlet fever and typhoid were frequently concurrent, as
Dr. Broadbent held. — Medical Times and Gazette, April 21, 1883.

The Pythogenic Micrococcus of Erysipelas.

The direct proof of the pythogenic nature of the micrococci of erysipelas has
been given by Fehlkiskx, who has not only found them present in all cases of
erysipelas (13 cases) which he examined during life, but also cultivated them,
and with equal success inoculated the cultivated organisms in animals and in man
(Die Aetioloqie des Erysipels, Berlin, 1883). In small portions of skin excised
from the diseased part in patients suffering from erysipelas, Fehleisen found in
all cases numerous micrococci arranged in chains. They were especially abundant
in the most recently affected part ; and here they were found most markedly in
the superficial layer of the corium and in the subcutaneous adipose tissue, filling
the lymphatics and the lymph-spaces, whilst the rest of the tissue showed cell-
infiltration. Contrary to the older observers, they were never found in the blood-
vessels. To prove that their presence was not merely accidental, Fehleisen cul-
tivated some small excised pieces of skin on gelatine, after having carefully dis-
infected the affected part, and succeeded, in the course of two months, in pro-
ducing fourteen generations. The cultivated micrococci formed a whitish film,
easily detached from the surface of the gelatine, and consisted entirely of the
specific micrococcus. Xine rabbits were now inoculated on the ear with the pui-e
and cultivated micro-organisms. In one the effect was merely a slight elevation
of temperature : in all the others, after thirty-six to forty-eight hours, the tem-
perature rose, and a characteristic erysipelatous rash appeared, and gradually
extended to the root of the ear, and thence spread to the head and neck. In
the course of six to eight days the disease had run its course, and the animal re-
covered ; not one of the animals died. The light red colour of the affected part,
the absence of oedema or suppuration, and the presence of the micrococci in the
lymphatics of the affected part (seen in one case, where the ear was amputated
during the height of the disease), showed that the affection produced in the
rabbit was true erysipelas, and not septicaemia.

More valuable still to show the etiological importance of the micrococci in ery-
sipelas are Fehleisen' s inoculations on man. Such a proceeding was perfectly
justifiable when we consider that many of the older and distinguished surgeons
(Ricord, Despres, Hebra, Busch, etc.), have quoted cases showing the thera-
peutic and beneficial effect of erysipelas when occurring in cases of lupus, cancer,
and other malignant tumours. Fehleisen inoculated the pure and cultivated
micrococci in seven cases. Of these, the first was a case of multiple, fibro-sar-
comata ; the second a case of cancer of the mamma, which had already been
operated on three times, and showed now several large tumours, adherent to the
skin ; the third, a case of intraorbital sarcoma, which had reappeared and grew
rapidly after enucleation of the eyeball for a primary intra-ocular sarcoma : of
the remaining four, two were cases of cancer of the mamma, and two cases of
extensive lupus of the face. Six out of the seven cases showed, after a period
'of incubation varying from fifteen to sixty hours, typical erysipelas, setting in
with rigors, high temperature, and running the characteristic course. In some
the symptoms were very severe ; in the first there was threatening collapse, and
the second was complicated with pleurisy, which, however, soon subsided. As

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regards the therapeutic effect, the inoculations are of some interest : one case of
lupus was almost completely cured (in the second case of lupus the inoculation
did not produce any erysipelas); in the second case the cancerous tumours com-
pletely disappeared, and there has been no recurrence so far ; in the case of the
orbital sarcoma, and in the other two cases of cancer there was no marked effect
produced ; whilst in the first case the fibro-sarcomatous tumours at first diminished,
but afterwards grew again in size.

As Fehleisen succeeded in successfully inoculating several cases twice after a
period of a few months, it appears that, if there be an immunity against a second
attack of erysipelas, that immunity is, in most cases, only of short duration.

Fehleisen also tried the effect of antiseptics on the vitality of the micrococci.
This portion of the researches might well bear extension, for only two substances
were experimented with, carbolic acid and corrosive sublimate ; a 3 per cent,
solution of the former stopped the growth of the micrococci after a contact of
forty-five seconds, whilst the same effect was produced in fifteen seconds with a
1 per cent, solution of the corrosive sublimate. From an etiological and patho-
logical point of view, Fehleisen's researches are of great importance, and the
list of diseases due to a specific micro-organism is thus enriched by one. As for
the practical outcome, further researches in different directions are needed ; and
it is with the hope of inducing some English observers to take up this subject
that we have given to Fehleisen's observations the prominence which they justly
deserve. — British Medical Journal, March 24, 1883.

The Diff erential Diagnosis of Urcemic Coma from the Coma of Cerebral

Hemorrhage.

Dr. T. A. McBride, in an article in the American Journal of Neurology
and Psychiatry, gives the differential diagnosis between uraemic coma and coma
due to cerebral hemorrhage. This is important, as statistics show that cerebral
hemorrhage is a very common accident in the course of chronic Bright' s disease,
and also that the hemorrhage is usually of large extent, and the accompanying
coma very pronounced. From a therapeutic point of view the distinction is very
important.

1. The temperature should always be taken in the rectum, with a self-register-
ing thermometer. In chronic Bright' s, and in the aged the temperature in the
axilla is often a degree or more lower than in the rectum. Charcot called atten-
tion to the fact that in cerebral hemorrhage at its beginning there was a fall of
cerebral temperature below 99°. This might be present from one to ten hours
or more, and until death in the fulminating form. This period of depression
may be followed by a continued and uninterrupted rise of temperature to 105°
or 108°. A high temperature occurring shortly after the advent of coma,
should have weight in ascribing the coma to urasmia.

2. Evidence of interference with the functions of the brain from some gross lesion,
i. e. cerebral hemorrhage producing hemiplegia. Hemiplegia is common in cere-
bral hemorrhages of large extent, and the hemorrhages of chronic Bright's are,
as a rule, large. The signs indicating the presence of hemiplegia due to lesion
of one of the hemispheres are : (a) Conjugate deviation of the eyes and rotation
of the head away from the paralyzed side and toward the hemisphere which is
the seat of disease, usually occurs as a temporary symptom in all cases of cerebral
hemorrhage, (h) Facial paralysis (cerebral). This may not be detected unless
the coma be not great, and passing off. (c) The limp condition of the upper and
lower extremities, but this sign is uncertain and not to be depended on. (d)
Exaggerations of the deep or tendon-refiexes on the hemiplegic side, (e) Abo-

1883.] Medicine. 255

lition of the superficial reflexes on the hemiplegic side, and their existence on the
sound side, (/) Increased temperature of the extremities of the hemiplegic
side, amounting to one or two degrees Fahr. (g) Erythema of the centre of the
gluteal regions. According to Charcot this usually shows itself from the second to
the fourth day after the seizure, rarely sooner and sometimes later. An eschar
forms very quickly in the site of the erythema, (h) The symptoms and signs of
uraemia ; high temperature, suppression of urine, a scant and bloody urine, accen-
tuation of second aortic sound, and a pulse of very high tension, oedema of lungs,
marked subconjunctival oedema, general anasarca, etc. — Amer. Journ. Neurol,
and Psychiat.., February, 1883.

Hemorrhage of the Nerve Centres in the Course of Purpura Hemorrhagica.
Dr. Duplaix, after a study of 24 cases, draws the following conclusions : 1.
There exist in the course of purpura haemorrhagica certain cerebral troubles of
great frequence, which depend upon certain cerebral lesions. 2. The cerebral
manifestations of purpura hemorrhagica are very variable in intensity, sometimes
but little marked and passing off' unnoticed ; again very violent, and causing the
death of the patient. 3. Their cause lies in some modification of the state of
the nerve centres — most frequently they are due to cerebral anaemia, though
in certain cases to hemorrhage. 4. As a rule these hemorrhages are but little
marked, though numerous, occupying sometimes the meninges, at others the
cerebral substance, and often both at the same time. 5. There may be true
hemorrhagic foci without a definite seat, whose consequences are those of ordi-
nary cerebral hemorrhage. 6. The hemorrhages are rare, on account of the
profound cerebral anaemia existing in most of these cases. 7. Their pathogeny
does not differ from those of other organs, but the condition of the circulation
and the vascular alterations must be noted, which have been marked especially
in the cases in which grave results have been delayed in debilitated patients. 8.
The clinical manifestations are very variable, and in proportion to the extent and
intensity of the lesions ; there are, however, cases in which, in spite of the
lesions, there have been no symptoms during life, and others in which anaemia only
has been observed, although the cases presented marked symptoms. 9. The
diagnosis of these cases is, as a rule, difficult. Hemorrhage should always be
suspected, in spite of the greater frequency of anaemia. The prognosis depends
on the intensity of the nervous troubles. — Archives G6n. de M6d., May, 1883.

A. Case of Tachetic Symmetrical Gangrene.

At a late meeting of the Clinical Society of London, Dr. Southey read the
following particulars of this case : —

Frank Nash, aged 9 (admitted into Matthew Ward, St. Bartholomew's Hos-
pital, November 25, 1881), was much emaciated, his hair thin and falling off,
abdomen empty and retracted, skin dry ; and he was in a curious, excitable, semi-
delirious mental state. He presented a gangrene of the tip of his right index
finger, all his extremities felt cold, and he had insomnia. His pulse was 148,
very feeble. Respirations 32. Temperature 99°. His heart beat with feeble
impulse, in the normal situation. There was no increase of normal cardiac dul-
ness ; no cardiac murmur ; no physical sign of lung disease. Neither liver nor
spleen transcended their normal limits. His appetite was bad ; he had had no
sickness ; the bowels acted once daily ; the tongue was clear and moist ; micturi-
tion gave no pain ; the urine was scanty, not abnormal, chiefly passed with his
stools.

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Progress of the Medical Sciences.

[July

Course and Progress. — After a few days the thumb and second finger of the
same (right) hand were similarly involved, became first red and throbbed, then
livid, and finally gangrened. On December 5th, an exactly similar spot occurred
on the pinna of the right ear, and on the extremity of his nose, and the tip of the
middle finger of his right hand. A little later, subcutaneous mottlings (tache-
t6es) appeared all over his trunk and limbs, and developed into a raised rash,
like urticaria tuberosa, or erythema-tubereulatum. The spots first itched, then
became painful and tender, but gradually subsided, leaving only some pigmenta-
tion to mark their sites. Finally, all the fingers and thumb of the right hand gan-
grened and slowly separated, and the thumb, index, and little finger of the Left hand.
He passed into a condition of most extreme prostration, with broncho-pneumonia
of both lungs, and only very slowly and gradually recovered from it. In January,
1882, a new and interesting clinical feature was manifested, namely, intermittent
true hematuria, bloody urine being passed alternately with normal-coloured non-
albuminous urine. Some days distinct blood- cells were passed with the urine ;
on others, blood colouring matter without blood-cells ; on others, albumen with
blood enough to give the blood reaction only. Oxalate crystals were present in
great abundance when the ha?maturia was abundant, and rice versa. No tube
casts were ever noticed. All symptoms of urinary disorder disappeared in July,
1882, when the child was discharged well, but with the loss of his fingers.

Dr. Andrew Clark asked if any history of rheumatic gout could be traced in
this case ? He was familiar with such forms of gangrene in this connection.

Dr. Sou they said he knew of nothing in the history to justify him in an
affirmative reply, and referred to the account of a very similar case to his own,
published in 1804, from the pen of a French physician, Reynaud.

Dr. Barlow said he had never seen so severe a case of the disease as that
described by Dr. Southey, but he had seen tAvo or three which were less severe.
As Dr. Southey had observed, the most important feature they presented was
not the gangrene, but the vaso-motor disturbances. In one case, within his own
experience — that of a man aged 35, who had been generally regarded as rheu-
matic— the attacks, which usually occurred during winter, were ushered in by
pain in the lower extremities, which was followed by the appearance of bluish-
red patches on the integuments. When first seen by Dr. Barlow, he had just
suffered an attack, and there was a distinct patch on one trochanter, while one
toe was the subject of local gangrene, and all his toes were blue. In two other
cases observed, in female children, 3j years old, the attacks occurred between
September and April, being rare in summer, and were in the latter case asso-
ciated with sudden changes in temperature. In one child the lower limb affected
was intensely painful and black from above the ankle to the toes when seen, and
presented a most alarming appearance. It remained thus for about three hours,
and then passed off", the child seeming quite well again. She had several attacks
of the kind in the legs and forearms. The attacks occurred on cold days in the
other case also, and on several occasions were accompanied with violent stomach-
ache, while, two or three hours subsequently, dark-coloured urine, containing
haematin, oxalate-crystals, and albumen, would be passed, but only once after
each attack. Dr. Barlow considered that the disease presented many points in
common with that known as paroxysmal haematuria. It was a disease of winter,
and was usually preceded by a condition of sleepiness ; its resemblance to ague-
attacks was not well marked, for there was no sweating stage observable, the
cold stage being the principal one. He had elicited from the mother of the pa-
tient presenting typical paroxysmal hasmaturia that the child's finger-ends grew
distinctly blue during the attack, and, so familiar was the appearance, that no
especial heed was paid to it. Dr. Barlow thought that the application of cold

1883.]

Medicine.

257

was a more rational treatment than the employment of warmth, being led to this
opinion from his knowledge of the effects produced by cold in the treatment of
frost-bites. He mentioned the case of a child which — a sufferer from paroxysmal
hematuria, and accustomed to be washed in warm water — was submitted to the
influence of cold water, with good results. The constant current applied down
the back had been employed by Reynaud, with a view to diminish the irritability
of the vaso-motor centres, and with success. A patient of his own had described
how this treatment was the only one which had done him much good while in
St. Bartholomew's Hospital, and the method was certainly worthy of extended
trial. There was no confirmation forthcoming of the association of rheumatic
gout with the disease in his cases. Mr. Hutchinson, however, had described a
connection between end-joint arthritis and Raynaud's disease, and a patient under
his (Dr. Barlow's) care might be taken to confirm this opinion.

Mr. Cripps took exception to the definition of Dr. Southey when calling the
affection a "blood" disease. He, himself, regarded it as an essentially local
complaint, and the gangrene as its principal feature. Such cases were analogous
to frost-bite, to the production of which no special bodily condition was neces-
sary, but simply exposure. Children who were attacked by symmetrical gan-
grene would be bound to have suffered from chilblains, which were an indication
of enfeebled circulation dependent on a Aveak heart. He cited the case of a
young woman who had been affected with chilblains, when living in reduced cir-
cumstances. She gave birth to a child, after which event she developed sym-
metrical gangrene, with the result that she lost both lower extremities. He did
not agree that it was right to apply cold or evaporating lotions to gangrened
limbs. Brodie's treatment, by wrapping the limb in cotton- wool and keeping it
covered, was wiser. Opium was the most reliable drug to employ ; given freely
in small but divided doses.

Dr. Barlow pointed out that he had not recommended the application of cold
in the treatment of gangrene, but in these cases of local asphyxia.

Dr. Mahomed had seen two cases similar to that mentioned by Dr. Southey.
In one intermittent hsematinuria had existed, and crystals of oxalates were found
in the urine. He explained that this frequent association of intermittent hsema-
tinuria with symmetrical gangrene effectually separated such cases from those
dwelt on by Mr. Cripps ; and, moreover, the patients in the former cases were
not necessarily endowed with a feeble circulatory apparatus. A few male patients
of his own had suffered from the disease in a more or less chronic form for seven
or eight years. The fingers presented a gangrenous appearance, which varied
with the weather, but was not improved by treatment. The tips of two or three
fingers had been quite lost. In summer time the hand was quite useful.

Mr. Symonds referred to several cases within his own experience, which pos-
sessed features in resemblance with those previously discussed ; they had lost the
tips of ears and fingers, and were now quite well.

Dr. Southey accepted Mr. Cripps's correction of the term "blood-disease,"
and substituted for it the description of a general disease, with local manifesta-
tion. Reynaud's account of it as being a vaso-motor disturbance was probably
accurate, but the etiology was very obscure. As a rule, local asphyxia was the
final stage arrived at as the result of the disease, the tendency to go on to gan-
grene being unusual. In one case, that of a woman, three fingers were seen, on
two separate occasions, to become quite purple, and, even during observation,
colour and sensibility were restored. — British Med. Journal, May 5, 1883.

No. CLXXI July 1883.

258

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A Case of Tabetic Arthropathy in which the Tarsal Bones of loth Feet were

involved.

At the meeting of the Clinical Society of London, held on April 13th, Mr.
Herbert Pag e read the following interesting account: This case was origi-
nally shown in the museum for living specimens at the International Medical
Congress. The patient was a man aged thirty, who, in October, 1880, began to
have swelling of his right leg and ankle. The foot gradually increased in size,
and when first seen in February, 1881, there was great enlargement in the region
of the tarsal bones, which were freely movable on one another in any direction.
A month later broken corns appeared on the sole, with an ulcer on the big toe.
These sores were absolutely painless, as, indeed, was manipulation of his foot —
a circumstance which led to the discovery that the patient was the subject of
tabes dorsalis, the knee-jerk being absent, and the pupils presenting the " Argyll-
Robertson phenomenon." There was no ataxia in gait. While under obser-
vation the left foot became affected in a similar way to the right, very rapidly
and without pain. Four years previously he had severe lightning pains down
the limbs, and two years before he had an illness called "nervous debility," of
which the most noticeable feature was profuse vomiting every day for nine
months, which began and ended quite suddenly without known cause as to its
origin or its termination — a true gastric crisis. Attacks of a similar kind have
occurred since the patient has been under the author's observation, and each of
them has begun with severe rigor, and been marked by the passage of large
quantities of blood in the urine, associated, at the same time, with profuse vomiting,
diarrhoea, and increased lightning pains. The patient has now been free from
these attacks for some months, and the swelling of the feet has subsided. The
feet, however, are strangely deformed, owing to an alteration in the relative po-
sition of the affected bones. The other symptoms of tabes dorsalis remain the
same, but there is still no ataxia. The history of this case having been given at
considerable length, the author avoided speculation about it, expressing the belief
that he should not do wrong to be content at present with the clinical study of
the disease. He pointed out the rarity of this particular form of arthropathy,
only one instance of which had been seen by M. Charcot. Though rare, it had,
however, many features in common with the arthropathies affecting the larger
joints. He, laid stress on the practical importance of recognizing these diseases
in the surgical wards of hospitals where they are most likely to be found, the
common symptoms of ataxia being often absent, and therefore rendering the
diagnosis more difficult. One foot of his own patient would in all probability
have been removed — so bad was it — had not the cause of the affection been acci-
dentally revealed by the symptoms. The arthropathy has subsided, however, and
left a useful, though deformed, limb. The occurrence of attacks of paroxysmal
hematuria was a striking feature in this case, and the association thereof with
the other symptoms of a crisis seemed to indicate that it was not less a symptom
of the disease than the vomiting, the diarrhoea, and the joint affections. The
history may therefore suggest a new line of observation and inquiry in the study
of these cases of paroxysmal hematuria or luematinuria, whose cause and origin
are so often obscure.

Dr. Althaus objected to the adjective " tabetic " on etymological grounds ; it
ought to be, he said, tabic or tabedosic.

Dr. Buzzard thought the remarks of Mr. Page anent the attacks of parox-
ysmal hsematuria or hasmatinuria of much import. He had met with no similar
case. It was possible that cases of apparently simple paroxysmal haemoglobi-
nuria were really the only manifestations of tabes dorsalis. He had frequently

1883.]

Medicine.

259

pointed out the remarkable association of the occurrence of the gastric symptoms
and the arthropathies. This was illustrated by reference to the report of a recent
case at one of the provincial medical societies. In this instance also there was
evidence of a healed perforating ulcer of the foot. Quite recently he had met
with an anomalous case, in which the left big toe-nail had become the seat of an
ecchymosis without any injury ; this had caused the separation of the nail, and
it turned out that precisely the same thing had happened last summer to the right
big toe-nail.

Dr. Mahomed related a case of locomotor ataxy, in which the earliest symp-
tom was atrophy of the optic discs ; there were characteristic pains, but no ataxia.
In this patient there was marked polyuria, as much as 180 ozs. being passed per
diem of a specific gravity of 1004. The polyuria was not permanent.

Mr. Page, in reply, quoted some facts from an American thesis, in which
spontaneous loss of nails and peculiar change of the toe-nails had been observed
in a number of cases. Regnaud had also described recurrent attacks of nephritic
colic closely simulating the violent attacks usually met with in cases of renal cal-
culi. Dr. Buzzard's suggestion that paroxysmal hematuria might really be due
to tabes dorsalis in some instances was further borne out by Mr. Page's case, for
the man had distinct attacks of shivering, which, had it not been for the collateral
acts, might have been attributed, as usual, to '-cold." — Medical Times and
Gazette, April 21, 1883.

Primary Stenosis of the (Esophagus.
M. Debove, in a communication to the Societe Med. des Hopitaux, gave an
account of a case of stricture succeeding a simple ulcer of the oesophagus. A
man, a?t. 54, without carcinomatous history, entered Bicetre in November,
1882. Had had soft chancres, and suppurating buboes in 1848, and several
attacks of delirium tremens. In December, 1870, he noticed that the passage of
food to the stomach produced sharp pain at the level of the xiphoid cartilage.
In March, 1871, he had three haematemeses, vomiting a quantity of black blood.
On going to a hospital an oesophageal sound was passed, after which deglutition
was less painful. In 1871 and 1872 the haematemeses recurred, and again in
1878, at which time the pain returning the oesophagus was catheterized several
times.

On examination at Bicetre two strictures were found ; one just above the cardiac
orifice, the other narrower and scarcely allowing the passage of an olive-pointed
sound of eight millimetres, at the level of the xiphoid cartilage. M. Debove thought
that it was a case of oesophageal stenosis running back ten years and showing two
distinct periods : The first prior to 1878, characterized by sharp pain in the pas-
sage of food, and by haainatemeses ; the second marked only by difficulty in swal-
lowing solids, nutrition being easily carried on by fluids, particularly milk. The
length of time during which the affection had lasted threw out the idea of a car-
cinomatous origin. The patient was not syphilitic, had never swallowed any
caustic solid or liquid, had no history of traumatism, and M. Debove diagnosti-
cated stenosis of the oesophagus following simple ulcer ; the first period of syrnp-
. toms corresponded to the evolution of the ulcer, the second to the cicatricial con-
traction. Quinke, who has cited three analogous cases, thinks that gastric juice
entering the oesophagus may be a cause of the affection. Debove thinks that
alcoholism was the cause in his. He obtained excellent results from dilatation ;
the man after treatment was able to swallow solid food. Dilatation was com-
menced on November 12, with a No. 14 olive; on November 25 a No. 20 could
be passed. After -December 5th the patient himself passed a lai-ge caoutchouc
sound, such as is used in artificial alimentation. Since that time deglutition has
been normal. — Gaz. Hebdom., April 20, 1883.

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Catarrhal Ulceration.

Prof. Virchow does not agree with Niemeyer in saying that, in acute and
chronic catarrh, ulceration or superficial erosion of the laryngeal mucous mem-
brane of the larynx may occur, and that the inflamed mucous membrane is then
in a condition analogous to the denuded cutaneous surface after the rupture or
puncture of a blister from a blistering plaster. At the same time Niemeyer de-
scribes follicular ulceration. Virchow holds that from the mucous membrane in
catarrh there is simply an excessive flow of its normal secretion, as may be seen
in the nasal membranes. This secretion, flowing from an unimpaired surface, is
the essential feature of catarrh, so much so that the phrase "dry" catarrh is
meaningless to the author, a contradiction in terms. Catarrhal ulceration is
equally unintelligible to Virchow. A child, he observes, may have an irritating
discharge of mucus from the nostril, which may accumulate about the nostril and
lip, and cause inflammation and ulceration thereof, but the ulceration being on
the skin, and not on the mucous surface, cannot be correctly termed catarrhal.
The ulceration of the larynx in phthisis is not catarrhal. The pavement epithe-
lium which extends from the lips to the cardia, with the exception of a small
spot at the border of the larynx, is not the seat of ulceration. Parts of the mucous
tract that are lined with cylinder epithelium are not thus exempt from ulcera-
tion, as may be often seen in the intestines after persistent diarrhoea, and in other
parts where glandular follicles exist. Virchow recognizes only as catarrhal the
secretion flowing from a simple mucous surface, and repudiates the application of
this epithet to any secretion from glandular structures. — London Med. Record,
May 15, 1883; from Berliner Klinische Wochensch., Nos. 8 and 9, 1883.

Antiseptic Inhalations in Pulmonary Disease.

Dr. Arthur Hill Hassall has recently been making some investigations
(Lancet, May 5, 1883) into the comparative inutility of antiseptic inhalations as
at present practised in phthisis and other diseases of the lungs.

It has appeared to him that the practice of such inhalations, which is now so
much in vogue, has not been shown to rest on any true or scientific basis or foun-
dation, and further that the clinical evidence in its favour is so far singularly weak,
notwithstanding the publication of a number of cases affirmed to have been bene-
fited thereby. Under these circumstances he has been led to institute a series of
experiments and observations with a view to test the efficacy of antiseptic inhala-
tion in the class of diseases mentioned, and he relates the results. The principal
antiseptic substances used are phenol, commonly known as carbolic acid, em-
ployed much more frequently than all the others ; and to which therefore the
most importance is attached ; creasote, which ranks next ; thymol, now coming
into more general use ; and iodine. His experiments show that the volatility of
phenol at ordinary temperatures is exceedingly slight ; it increases, however, in
proportion as the temperature is raised. The solution of phenol in alcohol and
chloroform he finds to lessen instead of increasing the volatilization. He finds
that it is extremely doubtful whether any portion of this antiseptic ever reaches
the air-cells of the lungs. This doubt is greatly strengthened by the fact that
the sputa in cases of phthisis brought up shortly after inhalation never, so far as
my experience goes, smell of carbolic acid ; neither has he ever found that acid
present in them in any notable quantity. Another fact corroborative of this view
may here be cited. The air expired during the inhalation of the carbolic acid
was passed through distilled water which was afterwards tested for the acid, the
faintest trace only being discovered.

1883.]

Medicine.

261

The next antiseptic experimented with was creasote. Xo volumetric chemical
process being known for the quantitative estimation of this compound, the gravime-
tric method had to be pursued, which, however, furnishes results sufficiently pre-
cise for the purpose. He finds that creasote is somewhat more volatile than
phenol, but still is of very slight volatility.

Thymol, which is a powerful antiseptic, he finds to be not in the least volatile
at ordinary temperatures, and that it is scarcely possible to conceive that it can,
as at present employed, exert any beneficial effect by inhalation.

In iodine we really have a volatile agent to deal with, and hence it might be
presumed that it did, in fact, make its way into the lungs. This conclusion,
though apparently warranted by the disappearance of the antiseptic during inha-
lation, is not confirmed by further observation.

When testing the saliva and mucus of the mouth and throat on the completion
of the inhalation with a solution of starch, he noticed that the colour of the starch
was unchanged, proving the absence of free iodine. On applying, however, an acid
to the mucus, the blue colour was abundantly developed, showing that very much
of the iodine inhaled, and possibly the whole of it, had become converted into an
iodide, in which transformation it loses entirely its antiseptic properties. This is
an interesting and important fact, not only in relation to the subject now under
consideration, but in other ways. Thus, for one thing, it shows how useless it is
to administer free iodine as a medicine. Again, it should be known that when,
as is frequently the case, carbolic acid and iodine are inhaled together, a strong
chemical action is set up between them, whereby probably the antiseptic proper-
ties of both are impaired. In the case of iodine, then, evidence is also wanting
to show that this antiseptic does really make its way into the lungs. Now it may
be urged that if the inhalation of the several antiseptics had been continued for
a longer period than an hour, the result would have been different — that is to
say, that more of them would have been inhaled. In order to test this point,
the inhalation of carbolic acid was continued for two hours in three experiments
with the following results : Of the 500 milligrammes taken, they were recovered
by Chandelon's process 410, 400, and 390 milligrammes respectively, thus show-
ing only a very moderate increase, quite insufficient to affect in any material
manner the general results arrived at. Even had the amount inhaled been much
greater, it would by no means have followed that a proportionate increase of the
antiseptic was to be found in the lungs. Supposing a small quantity of any of
the antiseptics really reaches those organs, it is not to be supposed that it remains
there for an indefinite time, and goes on accumulating as long as the inhalation is
continued. The action of the absorbents would doubtless come into play, and
the antiseptic which was inhaled the first hour would become removed by absorb-
tion during the second hour. Again, it might be urged that if smaller quantities
of the antiseptics were placed in the inhaler, the proportionate volatilization
would be greater. 250 milligrammes of phenol in water were sprinkled on the
sponge of the inhaler, and inhalation continued for an hour, at the end of which
time 234 milligrammes were recovered from the sponge, showing a smaller, and
not a larger, proportionate loss.

Iodoform in Chronic Pulmonary Affections.
Prof. Semmola was first to draw attention to the fact that iodoform, admin-
istered by the mouth, is in part eliminated unchanged by the lungs. Its probable
topical action during elimination led him to employ it in lung-disease. He and
many other good Italian authorities speak most favourably of its action, espe-
cially in caseous broncho-alveolitis, chronic pneumonia, and bronchial catarrh,

262

Progress of the Medical Sciences.

[July

bronchiectasis, etc. In phthisis, the expectoration often diminishes rapidly and
considerably, the cough is lessened, and the violent paroxysms disappear. The
products existing in the bronchi, or in a more advanced stage in the foci of soften-
ing and caverns, are disinfected. The fever progressively diminishes, and he
thinks that this diminution is in great part due to the local antiseptic action of
the remedy, and to the diminution of putrid matter, which, becoming absorbed
from the breaking up lung-tissue, represents one of the gravest consequences of
the morbid process. The general health evidently improves, and cases in the
first stage of caseous broncho-alveolitis may probably recover. The dose is from
one-eighth of a grain to six or seven grains a day, and must be determined by
the tolerance of the remedy by the digestive organs and the nervous system. It
is best given in the form of a pill, with extract of gentian or other extract. He
prefers to give it in small doses every hour, or every two hours. If it be not
well tolerated by the stomach, it may be given in inhalation, dissolved in oil of
turpentine, and administered three or four times a day. — London Med. Record,
May 15, 1883.

Nitric, Nitrous, and Nitro- Compounds in Angina Pectoris.
Mr. Matthew Hay. at the close of an elaborate, paper on this subject (Prac-
titioner, May, 1883), summarizes as follows : Briefly stated, the conclusions to be
drawn from the present experiments, and from those with nitrite of sodium, nitro-
glycerine, and nitrite of amyl, reported in my previous paper,1 are that nitrous
acid in any combination, whether as an ether or a metallic salt, is useful in the
treatment of angina pectoris; and, that, in the case of the nitrite of amyl, the
action of the acid is aided by that of the base. On the other hand, all compounds
of nitric acid, whether ethereal or metallic, are without effect, unless it so happen
that the constitution of the nitrate is such that it decomposes in the body with the
liberation of nitrous acid Further, nitro-substitution compounds have likewise
no remedial effect.

So far as at present known, the nitrogen-containing remedies for angina pec-
toris may be divided into two classes, the one consisting of combinations of nitrous
acid with metallic oxides or alcoholic radicals, the other comprising a peculiar
class of nitric ethers, obtained from the higher alcohols, whose decomposition
within the body results in the production of nitrous acid. In both classes the
action of the compound is ultimately dependent on the nitrous acid present.
Typical examples of the first class are nitrite of sodium and nitrite of ethyl, and,
of the second class, nitro-glycerine. To these classes might be added another
containing such substances as compounds of amyl, whose action is similar to that
of nitrites. Bat limited as this group at present is to compounds of amyl, it is
not one to be chosen in the treatment of angina pectoris. The dose required is
large, and the action is not rapidly produced, and disagreeable after-effects are
apt to occur ; and altogether I am very doubtful of its always acting so well as it
did in the case of my patient.

Treatment of Angina Pectoris.
Prof. Germain See, in a recent lecture on angina pectoris says : The medi-
cinal measures which I employ habitually are : 1. Bromide of potassium ; 2. Digi-
talis ; 3. Electricity (hardly habitually, but it deserves mention) ; 4. Arsenic (of
which the same may be said) ; it is sometimes of use as a vaso-motor tonic, but
its action is doubtful.

Loe. cit.

1883.]

Medicine.

263

Hydrotherapeutics ought to be absolutely proscribed.

1 . Bromide of potassium determines contraction of the bloodvessels, calms the
nervous system (particularly the centres of special sense), and induces sleep; it
is a regulator of the peripheral movements of the blood. Under its action the
patient becomes less impressionable to the physical and psychical influences which
might provoke a return of the paroxysm. But this medicine has the grave incon-
venience of producing a debility which is more or less permanent, and cannot be
continued with impunity beyond a certain time.

2. Digitalis, when the thoracic angor results from cardiac atony or degenera-
tion, presents a real advantage over the bromide ; it fortifies and sustains the
action of the heart, and is in every way the preferable medicament.

3. Electricity has been applied in divers ways, and in accordance with the
different theories which have been put forth as to the nature of the malady. If
employed from confidence in the pneumogastric-nerve theory of Eulenburg,1 and
an attempt be made to galvanize this nerve, you may run the risk of arrest of the
heart's action ; the unfortunate case reported by Duchenne is in proof of this. —
New York Med. Journ., May 26, 1883.

Purulent Pericarditis, Paracentesis, and Free Incision — Recovery.

At the meeting of the Royal Medical and Chirurgical Society, on April 24th,
Dr. Samuel West reported the very interesting case of a boy, set. 16, who had
a large pericardial effusion. The symptoms became so urgent that paracentesis
was performed. Pus was obtained. Three days later paracentesis was again
performed, and subsequently the pericardium was laid freely open, evacuated,
washed out, and a drainage tube inserted. The temperature never rose, and the
boy recovered completely in five weeks, the only feature of interest being an
attack of general urticaria, which came on about a week after the operation, and
lasted three or four days.

In support of the diagnosis, a case of Sir J. Risdon Bennett's was referred to,
in which what was supposed to be mediastinal cyst was frequently punctured, but
proved to be on post-mortem examination a case of chronic pericardial effusion.
The points of clinical interest discussed were : 1. The absence of any special
signs to indicate the nature of the effusion ; there was no friction to be heard
before the operation, or mill-wheel sound characteristic of hydro-pneumo-peri-
cardium after the free incision; 2. The operation (which was by preliminary
puncture with a small trocar and cannula, and subsequently by free incision) , and
the place selected for puncture, viz., the fourth intercostal space, immediately
below the left nipple; 3. The amount of the fluid evacuated, viz., fourteen
ounces by the first tapping, and about two quarts by the free incision ; 4. A
peculiar epigastric prominence, noticed before paracentesis, which disappeared
after operation ; 5. The attack of urticaria ; 6. The pulsus paradoxis, which was
constant up to the time of the free incision, but ceased immediately after that. A
short account was then given of the only other recorded case of incision of the
pericardium for purulent pericarditis by Professor Rosentein, of Leyden, which
also recovered.

Dr. West then gave the following resume of the history of the operation, which
was first suggested by Riolan, in 1649. Its practical introduction was traced to
Dr. Rovers, of Barcelona, who operated successfully in two cases, in 1819. In

1 Eulenburg, "Traitedes maladies nerveuses," 1878. He describes two forms of
the disease, one of which is due to direct excitation of the vagi nerves, the other to re-
flex excitation of these nerves. He also describes two other varieties of different nerve
origin.

264

Progress of the Medical Sciences.

[July

1841 there was a remarkable series of cases in an outbreak of scurvy in Russia,
in which the pericardial effusion was composed mostly of blood. Nine were
operated upon and six recovered. In 1854 Trousseau's essay was published
upon some cases of his own and of M. Aran, which revived interest in the sub-
ject. In 3866 Dr. Clifford Allbutt introduced the operation to this country, and
it was performed by Mr. Wheelhouse and Mr. Teale. Rosenstein, in 3 871,
made a gi-eat practical advance in operating by free incision with drainage. A
complete list of the recorded cases up to date was given in a tabular form, with
the addition of several cases hitherto unpublished, making 79 cases in all. Of
these, 5G had been in males, for which no reason could be assigned, and they had
been uniformly distributed over the early ages of life. Phthisis and pleurisy
had been associated with 23 cases, rheumatism with 11, scurvy with 9, general
dropsy with 5, injury with 3; in 3 2 cases there had been no associated disease.
The fluid had been in 58 cases serous, in 12 purulent, in 9 bloody. The amount
evacauted had been in 46 cases less, in 33 cases more than a pint. It was not
rare to evacuate as much as two or three pints. The largest quantities had been
found in the scorbutic cases, and from one of these about ten pints had been
evacuated. It had been sometimes observed that ^reat relief was criven by the
withdrawal of one or two ounces, and that this had been followed by the absorp-
tion of the rest of the fluid. Dieulafoy's careful experiments had led to the
selection of a place in the fifth left space, about an inch from the sternum, as the
safest point for puncture. The following conclusions were drawn : 1. Paracen-
tesis pericardii is not only justifiable, but an operation which may be safely
undertaken with ordinary precautions, for only one case is recorded in which the
operation was in itself fatal, and, with this exception, all the patients were greatly
relieved by the removal even of small amounts of fluid, and many recovered com-
pletely who would probably have died had the operation not been performed.
2. The most suitable place for puncture is, in ordinary cases, in the fifth left
intercostal space, one inch from the edge of the sternum ; but, if the pleura be
adherent, the puncture may be made safely much further out, and even in the
sixth space. 3. The instrument employed should be a trocar and cannula, with
or without aspiration. 4. The operation may be performed with advantage, not
only in the pericardial effusions of rheumatic or primary origin, but also in those
which occur in the later stages of general dropsy, if it should appear that the fluid
in the pericardium is adding to the difficulties under which the heart is placed.

5. Purulent pericarditis is best treated on general principles, like empyema.

6. The pericardial sac may be safely opened and drained. 7. This treatment,
moreover, appears to be the only one which offers the slightest hope of recovery.
8. The results do not seem to be as unfavourable as those of empyema, for the
walls of the cavity are better able to contract rapidly, and thus permit its com-
plete obliteration.

Mr. Hulke hoped he should not be intruding on a subject of special interest to
the physicians, if he made one or two remarks on the case which had been so
admirably treated by Dr. West. He considered it more advisable to dissect
down carefully to the pericardium before any incision was made : and, if a trocar
and cannula were employed, he advised very cautious use of them, and that the
trocar be frequently withdrawn, to form an opinion of the parts reached. He
had himself, after medical consultation, in a case which was believed to be one
of pericardial effusion, once inserted a trocar and cannula somewhat boldly, and
the withdrawal of the trocar had "been followed by a jet of blood, which gave
him great anxiety, but happily relieved the patient. A subsequent post-mortem
examination showed him that he had punctured the right ventricle, and that the
case was one of universally adherent pericardium,

1883.]

Medicine.

265

Dr. T. H. Green expressed some doubt as to whether the diagnosis of peri-
cardial effusion should have been made in a case where no pericardial friction
was heard, and in which the cardiac dulness did not extend higher than the upper
border of the third rib, as was shown in Dr. West's diagrams. He advised pre-
liminary exploratory puncture as in pleural effusions, but said the relief to be
expected in the draining of the pericardium was less than in cases of empyema,
for the cause of death in chronic pericardial effusion was rather the damage done
to the cardiac muscle than the pressure of the pericaixlial fluid.

Dr. Southey congratulated Dr. West on his results, and remarked that the
origin of the purulent pericarditis in his case was obscure ; it certainly was not
rheumatic, and there seemed to be no history of any such injury as sometimes
set up purulent pericarditis after several weeks. He was inclined to suppose that
the suppuration had not begun in the pericardium, but had extended into it from
a neighbouring abscess ; and in that case the low level which the upper border of
the dulness reached would be explained. The dyspnoea and orthopnoea, he ad-
mitted, were sufficient grounds for interference ; and he inquired if any difficulty
of breathing had been noticed over the lower lobe of the left lung, such as was
usual in cases of large pericardial effusion. He quite agreed with Mr. Hulke in
advising cautious procedure and dissection before incision. Dr. West had men-
tioned one case only in which paracentesis had been immediately fatal, and he
imagined that that was a case which they had both seen together ; but he quoted
a case of Bouchut's, and another within his own knowledge, in which there had
been death within a short time. The pulsus paradoxus in these cases had first
been noticed in an essay by Kussmaul, in 1869.

Mr. Marshall remarked that the old methods of procedure, which were some-
times by excision of a portion of the sternum or costal cartilages, were shown to
be quite superseded. The soft elastic area at the epigastrium, which Dr. West
had mentioned, pointed somewhat to a diagnosis of mediastinal tumour ; and the
rapid closure of the wound in thirty days was hardly to be expected if the inci-
sion had been in the pericardium and there had been constant motion of the
heart to prevent healing. He asked if there had been any signs of endocarditis,
or any cerebral symptoms, so common in purulent pericarditis.

Dr. S. West expressed himself as having felt guilty of timidity rather than of
boldness in his treatment of the case ; and that was perhaps' not unnatural, as he
had previously only seen one case of paracentesis pericardii — the same, he be-
lieved, as that to which Dr. Southey had referred ; and there death had been
immediate. The trocar and cannula used in his first tapping had been very
small, and had been introduced very cautiously ; it had only been thrust in up to
its hilt when he had convinced himself that it was in a free cavity. There were
some cases in which a correct diagnosis of pericardial effusion was almost impos-
sible ; and in some of these the right ventricle had been punctured, as in the case
Mr. Hulke had related. He had not entered these cases in his tables. Often
no harm had followed ; and, indeed, in America, there were several cases in
which the right ventricle had been intentionally tapped, and the operation had
given some relief. Laceration of the ventricle, rather than mere puncture, had
proved the fatal injury. He had not been surprised at the absence of pericardial
friction in his case ; nor had he felt it a point hostile to his diagnosis, for he
imagined that, when he first saw the case, the effusion was too great to allow
any rubbing together of the pericardial surfaces. The upper limit of dulness,
which he had marked in the diagnosis was the limit of absolute dulness, and,
he thought, was quite consistent with large pericardial effusion. That death was
due in such cases to the pressure of the fluid on the heart, rather than to the
degenerate state of the heart's muscle, as Dr. Green had suggested, was shown

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by the relief afforded by the evacuation of the fluid. The pulsus paradoxus was
not characteristic of pericardial effusion, but occurred in other cases where there
was fibrous thickening in the mediastinum ; and recent experiments had shown
that it was due to mechanical pressure on the inferior vena cava, by which the
complete filling of the heart was prevented. The condition of the epigastrium in
his case was similar to that in Dr. Allbutt's case, which was one of undoubted
pericardial effusion, and argued against his case having been really one of me-
diastinal tumour. He had observed no endocarditis, but did not feel that that
was any argument against the pericardial nature of the case ; for endocarditis
would only be expected, as Dr. Southey admitted, in a rheumatic case, and lie
had not anything to lead him to suspect that his case was rheumatic. — Brit. Med.
Journ., April 28, 1883.

Perisplenic Abscesses.

M. C. Zuber, in a study of encysted purulent collections of the peritoneal
cavity, draws the following interesting conclusions regarding perisplenic ab-
scesses : —

1. Perisplenic abscesses are purulent collections in the upper part of the ab-
dominal cavity, only partially touching the spleen, and by no means confined to
the cellular, subserous tissue of that organ. They are more usually situated in
the irregular space bounded by the stomach, the spleen, the colon, and the dia-
phragm, and are the result of a circumscribed peritonitis, due, ordinarily, to
lesion of the spleen or digestive tract. Infectious splenitis (including paludal
lesions), and round ulcer of the stomach appear to be the most usual factors in
the causation of these abscesses.

2. Purulent collections, due to lesions of the digestive tract, contain gas, and
this complication is shown by a symptomatic list of remarkable constancy, resem-
bling, more or less, the symptoms of pneumothorax, but distinguished from the
latter affection by the fact that the diaphragm is forcibly pushed up. Its nature
is also recognized by the grave symptoms on the part of the digestive organs, fol-
lowed by variability, exaggeration, or insufficiency of the physical signs.

Purulent collections of splenic origin are characterized, to some extent, by
tumefaction, and pain in the hepatic region, and the general symptoms of latent
suppuration, rarely by more or less marked and fluctuating tumours. The diag-
nosis must generally be made by exclusion.

3. These abscesses are not beyond the reach of modern surgical art. Frequent
and deep exploratory punctures should be made, and when found the pus should
be evacuated. — Gaz. Hebdom., April 13, 1883.

Habitual Constipation.

Dr. J. Mortimer Granville gives the following three prescriptions for the
treatment of habitual constipation. He regards persistent inactivity of the bowels,
when not demonstrably due to other causes, as the result of, either defect of peris-
taltic action ; deficient glandular secretion ; or, interruption of the habit of periodic
evacuation.

1. When there is a lax and torpid condition of the muscular coat of the ali-
mentary canal, we get food retained in the stomach or intestines until it ferments,
or sometimes " decomposes," with the result of distension, pain mechanically in-
duced, and either eructations or incarcerated flatus. I have recently seen a very
considerable number of cases in which this last mentioned trouble had been so
great, and at the same time so masked, as to have given rise to the impression

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Me d i c i n e .

267

that grave disease existed ; whereas every anomalous symptom has quickly dis-
appeared as soon as the muscular tone has been restored, and the contents of the
bowel have commenced to pass naturally on their course. The essential fault is
partial, in some instances almost complete, loss of the reflex contractility of the
muscular coat, so that the presence of ingesta at any part of the canal does not
excite the intestine to contract and propel it onwards. It is worse than useless
to employ ordinary aperients in such a condition as this ; they only irritate, with-
out strengthening, the nerves on the healthy activity of which everything depends.
When, therefore, this is the form of "constipation" which requires treatment,
I give a prescription something like the following; and it is, in the majority of
instances — of course nothing is uniformly — successful.

R. — Sodae valerianatis gr. xxxvj ; tincturae nucis vomicae Tltlx ; tincturae capsici
Tft xlviij ; syrupi aurantii ^jss; aqua ad 3yj. Misce, fiat mistura, cujus sumatur
cochleare magnum ex aqua ter die semihora ante cibum.

2. The second form of constipation, in which there is a deficiency of glandular
secretions, generally throughout the intestine, manifested by a peculiarly dry and
earthy character of the dejecta when the bowels do act, I treat by a mixture such
as this : —

R.— Aluminis ^iij ; tincturae quassias ^j ; infusi quassiae §vij. Misce, fiat
mistura, cujus sumantur cochlearia duo magna ter quotidie, post cibum.

3- The third form, which depends chiefly on interruption of the natural habit
of periodic discharge, often results from repeated failure to move the bowels, in
consequence of one or other of the two preceding forms of this trouble. This
may generally be relieved by directing a perfectly regular attempt to go to stool,
and by the use of the following draught, taken the first thing after rising from
bed — not on awaking — in the morning, as nearly as possible at the same hour. It
will be observed that it is not an aperient in the ordinary sense of the term. It
is, as a rule, neither necessary nor desirable to continue it for longer than a fort-
night. In most instances, it will be found to re-establish the normal habit in a
week or less : —

R. — Ammonias carbonatis gj ; tincturae Valerianae ^j ; aquae camphorae ^v.
Misce, fiat mistura: capiat partem sextam in modo dicto. — British Medical
Journal, May 26, 1883.

Percussion of the Colon in the Diagnosis of Diarrhoea.

Dr. Goedicke calls attention to the importance of percussion over the colon
in diarrhoea, as a means of diagnosing between the different types of the affection,
and, consequently, as an indication for treatment. Having proved, by careful
observation, the fallacy of his first idea, that diarrhoea must necessarily be accom-
panied by an empty colon, and consequently a tympanitic percussion-note, he
instituted a systematic percussion of every case which came under his observation,
which led him to the following conclusions. 1. On percussion of both iliac fossae
in a healthy individual with regular evacuations, the (relative) dulness is gener-
ally found on the left side. 2. In patients suffering from diarrhoea, the dulness
is found sometimes on the right side, sometimes on the left ; oftener, in Dr.
Goedicke' s experience, on the left, in otherwise healthy persons, in whom the
diarrhoea has not been long continued. 3. In children, the proportion is the same.
4. If pain on pressure be present, it is on the same side as the dulness. 5. The
dulness is always to be understood as being merely relative; the actual note may
even be loudly tympanitic, if the intestine is inflated by gas. Dr. Goedicke
divides ordinary catarrhal diarrhoea into two groups, equally distinct in symptoms
and in treatment. The first, which is the most common, occurs in otherwise

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healthy persons as the result of a chill or of an error in diet, supervening upon
some derangement of the normal relation between the food and the reflex sensi-
bility of the intestine, which has caused an accumulation of feces in the lower
bowel, in spite of a daily evacuation. The symptoms are severe, cutting pains
across the abdomen, following directly on the ingestion of food, and accompanied
by urgent calls to stool, and the evacuation of fluid stools, mixed with shreddy
masses, and very offensive, which may attain a frequency of sixteen to twentv in
twenty-four hours. The appetite is generally good, and the tongue clean ; there
is no fever, and the pulse is normal in strength and frequency, although a beat
may be occasionally intermitted. The abdomen is prominent, and any tender-
ness which may be present is found in the left iliac fossa; but the point on which
the author lays most stress is the greater relative dulness on percussion on the
left side, which is constantly present, whether the other symptoms be well-marked
or slight. This is the form of diarrhoea which is met with in infants and children :
and its proper treatment in all cases is mild purgation, opiates and astringents
being contra-indicated, although a dose of opium may be given at first if the pain
be very severe, or if it be advisable to let the exhausted patient have a few hours'
rest before the laxative action commences. Dr. Goedicke recommends decoction
of frangula for adults, and small doses of calomel for children. The diarrhoea of
the second group has its seat in the small intestine, and is the form most often
treated of in text-books. The patients have been cachectic and delicate, with
feeble digestion, and are sometimes tuberculous. The exciting cause may be an
error in diet, or a chill, but often there are only to be found symptoms of the
existing cachexia. The abdomen is soft and sometimes retracted, but it may be
distended from meteorismus, and there may be gurgling in the ileo-caecal region.
In all cases, however, the relative dulness is found in the right iliac fossa. The
appetite is small, and the stools seldom exceed two or three in twenty-four hours,
but they are copious and watery, and are generally unaccompanied by pain. The
treatment in these cases consists of opiates and astringents, with suitable diet,
warmth, etc. The author concludes his paper with the opinion that the more
percussion is employed in cases of diarrhoea, the more will opium as a remedy
retreat into the background. — London Medical Record, May 15, 1883; from
Deutsche Medicin. Wochensch., No. 7, 1883.

Alterations Produced by the Distoma Haematobium in the Urinary Passages and

Large Intestines.

Dr. Zaxcaual. Physician in Chief of the Greek Hospital at Alexandria, has
recently presented a memoir to the Medical Society of the Hospitals of Paris on
this subject.

The Distoma Haematobium is a trematode of separate sexes. The male is
cylindrical, measuring about T4^ inch in length, and possesses a cavity into which
the female is received during the act of fecundation. The female is longer than
the male by about inch, is thinner and more filiform. The ordinary habitat of
the trematode is the blood of the portal vein, the mesenteric, vesical, and hemor-
rhoidal veins. The male is provided with two suction apparatus which enable
it to fasten itself to the walls of the bloodvessel. The existence of the eggs and
embryos of the parasite in the urine, which becomes bloody from alteration of the
vesical mucous membrane, and their more rare presence in the fecal matters, is
the means of determining their presence in the organism. The presence of eggs
in the substance of the tissues shows grave pathological lesions. Zancaral pre-
sented two specimens showing this, from two patients. One died with symp-
toms of chronic intestinal ulceration. The autopsy showed that the walls of the

1883.]

Medicine.

269

descending colon, the sigmoid flexure and the rectum, more thickened and en-
larged almost entirely at the expense of the mucous coat. The internal surface
was converted into a mass of vegetations having the appearance of hemorrhoids.
These vegetations run from ^s to T6ff of an inch high, with a very enlarged base. In
the intervals the surface is sometimes granular, sometimes smooth. In some cases
the vegetant and granular forms are united. These lesions are due to infiltration
of the mucous membrane by the eggs of the distoma, and if a microscopic exami-
nation be made of the submucous layer, it is seen to be full of the eggs, the same
being true of the tubular glands. The eggs are ovoid, shaped like a pumpkin
seed, about mm. 0.170 long, and often present a lateral spine, which is only
found in the eggs of the intestinal tunics. In the urinary apparatus this spine is
at one extremity of the egg. The eggs are undoubtedly laid in the hemorrhoidal
veins, for it is here that the adults of both sexes are found. The mechanism of
their passage through the walls of the vessels into the tissues is unexplained.

The second specimen presented was from a man dead of urseniia, in whose
urine the eggs had been found during life. The kidneys were much enlarged,
surfaces crumpled, containing cystic cavities, and the distinction between the cor-
tical and medullary substance had disappeared, the renal structure was composed
solely of an homogeneous layer, and was indurated. Some small pisiform ab-
scesses were found in them. The ureters were enlarged and tortuous, the walls
considerably thickened, the internal surface velvety. The walls of the bladder
were enormously hypertrophied, and l ,2j inch thick, the cavity being about the
size of a walnut. The hypertrophy was mostly at the expense of the muscular
layer, which was very hard. Microscopic examination showed that the eggs ex-
isted in small quantity in the superficial layer of the vesical mucous membrane,
the epithelium having disappeared. The right kidney presented the ordinary
lesions of hydronephrosis, the left those of advanced interstitial nephritis. The
patient, then, had had cystitis caused by the eggs of the distoma, and this affection
caused the lesions of the ureters and kidneys ; for the eggs were not found in the
kidney in this case, and are so found only exceptionally. The disease is not
always fatal, as has been stated in certain works on the subject ; the evidence of
it being found in a great number of Arabs, some of whom recover. — Journal de
M6d. de Paris, May 19, 1883.

Leucoderma.

Dr. Thomas F. Wood, of North Carolina, in describing a case of leucoderma,
occurring in a negro woman, who had a carotid aneurism, but was otherwise in
good health, says: The course of the increase of the area of leucoderma was not
steadily progressive, but in waves. This patient was examined at varying in-
tervals, and the margin of pigmented patches carefully traced upon her photo-
graph. It was discovered that the black patches would recede on one side, and
increase upon the other ; and especially upon the face the margins were not so
abruptly black at all times, but fading into the white by imperceptible gradation.
The increase of absorption rapidly advanced in the five years preceding this
writing, until now she has more the appearance of a blonde white woman with
black patches on her face.

The condition of the skin is very peculiar. To the casual observer it appears
much thinner than the skin of a negro, suggesting the idea of the obliteration of
the rete mucosum. So highly sensitive is it that a moderate sun burns and the
intense summer sun blisters it. The slightest scratch causes free bleeding, and
nose-bleed is easily provoked, and recurs again and again. The nasal tract is
exceedingly sensitive, and, as I have remarked in another place, does not bear

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out the theory of Mr. A. It. Wallace, that the deficiency of smell in some animals
is due to the absence of pigment there, for this patient has unusual acuteness of this
sense.

It is well known to those physicians who have watched syphilitic diseases
among these people that the shade of their skin frequently changes to several
degrees lighter, and that this change is permanent and uniform over the whole
body. The lack of complete analogy between this sort of alphosis and leuco-
derma, strictly so-called, is that the transformation does not occur in patches.

I reported a case some years ago (1876) in the London Medical Examiner of
a very black negro who had leucoderma succeeding typhoid fever. He had no
white patches previously. His business was that of a sawyer, and exposure to
the rays of the sun upon newly sawed lumber became very painful to him. This
man's hair did not turn white, nor did his skin become so sensitive, and there
was not that abrupt demarcation between the white and black as in the case
above reported. After several years of rapid alphosis, pigmentation began
again, and I am able to reaffirm what I previously reported, that the process still
continues. The skin is not becoming so black as natural, but the change has
been repeatedly noticed by his friends.

These three types of alphosis may lead us in the future to a more correct study
of the causes. 1. We have leucoderma in a woman who had no noticeable
change in her health from beginning to end. 2. We have the entire skin chang-
ing several hues lighter after an attack of constitutional syphilis. 3. We have
a leucoderma succeeding convalescence from typhoid fever, in which there is
resorption of pigment, and a gradual redeposit. Are these all examples of a
different disease? Or are they different manifestations, varying degrees of a
process which has a central origin elsewhere than in the skin? — Journal of Cu-
taneous and Venereal Diseases, June, 1883.

SURGERY.

Transplantation of Skin-Flaps from Distant Parts without Pedicle.

Dr. J. R. Wolfe, Senior Surgeon to the Glasgow Ophthalmic Institution, has
lately written an interesting paper on this subject (Practitioner, May, 1883), in
which he says, that while practising M. Reverdin's method of skin-grafting in
which little bits of the size of a pin's head are taken and arranged in mosaic
fashion upon the ulcer, or upon the site of deficiency of the skin, he was never
satisfied with the macadamized appearance of the parts. He also noticed a very
important fact in connection with skin-grafting, namely, that the graft which was
taken clean adhered satisfactorily, while the bits which had a bleeding under-
surface did not adhere to their new site. He thus became convinced that the cause
of non-success in transplantation was the areolar tissue underneath, and that, if
we could transplant a skin-flap free of that subjacent tissue, we should secure its
adhesion and incorporation. To put this to the test, he operated in one case in
which the skin required for the eyelid was two inches in length by one inch in
breadth. He removed the flap from the forearm in three portions, separating the
first from its cellular tissue as closely as compatible with the integrity of the flap,
but turning up the other two after removal, and with a knife slicing off the areo-
lar tissue so as to leave a white surface, which I then applied to the eyelid. The

1883.]

Surgery.

271

difference between these flaps was very remarkable. The two which were pre-
viously prepared healed by agglutination, without even desquamation of the
cuticle. Twenty-four hours after the operation, the surfaces looked pale, but the
next day the temperature was normal, and the appearance healthy. The part
which had been applied without previous preparation looked rather livid the first
day, improved for the next two days, but on the fourth began slightly to suppu-
rate, and, after a hard struggle for life, only a portion of it remained and the rest
shrank. This, however, did not compromise the result of the operation, which
was on the whole satisfactory, and he was therefore enabled to formulate the con-
clusion that, if we wish a skin-flap to adhere to a new surface by first intention or
agglutination, we must be sure that it is free of all areolar tissue, and properly
fixed in its new place. When thus prepared, we may cut the flap of any shape
or size from any other part, or from another person, and transplant it without
pedicle.

Removal of Extensive Cavernous Angioma of the Scalp by the Elastic Ligature.

Dr. George R. Fowler, of Brooklyn, gives the details of the following in-
teresting case: Lizzie K., set. 6 mos., was presented at the East Brooklyn
Dispensary Clinic, Jan. 30, 1883, with the history of a congenital tumour, which
had been slowly enlarging, although it had apparently caused the little one no
particular uneasiness. Upon examination there was found an ovoid tumour,
moderately soft and elastic, having no communication with the brain, but situated
external to the right parietal bone at its posterior superior angle, covering an
area about 7 cm. by 5 cm., and its entirety raising the scalp about 2 cm., entirely
subcutaneous, of a bluish colour, and seemingly made up of enlarged capillary
vessels and fibrous tissue. Its position favoured free anastomosis of branches of
the occipital and posterial temporal arteries ; no pulsation, however, could
be felt.

On February 2d the following operation was performed : No anaesthetic was
used. The scalp was first thoroughly washed with a 1 to 40 solution of carbolic
acid, and ordinary antiseptic precautions adopted. Four straight needles without
cutting edges were selected, threaded with common band elastic of pure gum
rubber, and passed subcutaneously beneath one side of the growth in succession,
each successive needle with its ligature entering at the point of exit of the last
one.

Next the ends of the elastic were re-threaded in turn, and the needle in each
case made to re-enter the original puncture, and keeping well down to the base
of the tumour it was carried through and out of the opposite side. The remain-
ing ligatures were carried across the base in the same manner in turn. The pro-
jecting ends of each loop were passed through apertures in a narrow strip of
sheet lead, then grasped by dressing forceps, made tense, and finally secured
while thus tense by clamping with split shot.

The entire mass was inclosed subcutaneously in four loops of elastic ligature,
and subjected to gradual, yet firm, constant pressure. It was hoped that heal-
ing would take place behind the ligatures as they cut their way gradually through
the base of the tumour, as occurs when a fistula-in-ano is treated in an analogous
manner, therefore as much tension was not placed upon the loops as might have
been exercised. Hemorrhage was avoided, the entire operative procedure being-
completed with but slight oozing from the punctures in the scalp, and the atten-
dant pain was surprisingly slight, not justifying the use of an anaesthetic. The
parts were covered with powdered naphthalin and absorbent cotton, drop doses

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Progress of the Medical Sciences.

[July

of deodorized tincture of opium, ordered in case the child gave evidence of suffer-
ing pain.

On February 6th the dressings were removed, the ligatures tightened, again
clamped with drilled shot, and redressed as before. No hemorrhage. February
11. — Ligatures have cut completely across base of tumour, and the latter is held
loosely attached to the scalp by the portions of integument between the points of
original entry of ligature. These were encircled with other elastic loops, when
the complete separation of the mass occurred. The parts were then dressed with
iodoform.

On February 13th, the surface was irrigated with 1 to 40 carbolic solution, and
dressed with naphthalin. February 14. — Redressed with naphthalan. Granu-
lating healthily. February 19. — Applied five skin grafts containing hair follicles,
and dressed with naphthalin gauze. February 24. — Four of the grafts appear to
have taken. Redressed as before. March 5. — New skin formation from margin
of grafts extended to circumference of original granulating surface. — Annals of
Anatomy and Surgery, June, 1883.

Tracheotomy in Croup and Diphtheria.

Dr. H. Lindner has recently published (Deutsche Zeits. f. Chir., Bd. xvii.,
Hft, 6) 106 cases in which tracheotomy had been performed in hospital and
private practice for croup and diphtheria, by the author himself or under his
direction. In one of these cases death occurred on the operating table, and in
another, in which the condition was quite hopeless, the operation was performed
in order to keep the patient alive until the arrival of the parents. Of the 101
remaining patients sixty-three died, or 62^ percent.; and thirty-eight, or 37f
per cent., recovered. In seventy-nine cases in which obstruction of the air-pas-
sages was the prominent morbid condition, forty-four, about 55.7 per cent., were
fatal ; in the twenty-two cases in which this condition was subordinate to symp-
toms of intense general infection, all the patients died. A tabulation of the
author's cases, giving the proportion of deaths and recoveries at different ages,
seems to indicate that after the second year there is a marked change in the rela-
tion of successful to fatal cases. Whilst in the second year the mortality is 88.8
per cent., in the third year the percentage of recovei-ies is 55. The author re-
frains from drawing any positive conclusions from these figures. The reduced
proportion of fatal cases with advance in years might in his practice have been
due to chance, and other and more extensive tables might show quite different
relations. The proper time for operating, it is thought, is that when well-
marked retraction of the scrobiculus cordis is first observed. If the surgeon
delay in operating far beyond this stage, the prognosis becomes very unfavour-
able ; and, on the other hand, if he decide on intervening at an earlier date, he
may see his patient recover after the proposal to operate has been rejected by the
friends, an event, Dr. Lindner states, which would serve neither the reputation
of the doctor nor a desirable popularization of the operation. Lnfortunately,
in most cases, as the child is often brought to him at too late a period, the sur-
geon is seldom able to operate at the first appearance of this special indication.

In all save five of the tabulated cases, Dr. Lindner performed superior trache-
otomy. In one case only was the operation done below the isthmus of the
thyroid gland. In two cases the isthmus was divided. Considerable hemorrhage
resulted in these, and also in one- case in which a much swollen thyroid gland
was lacerated. The superior operation, he holds, is specially indicated in the
case of an infant, or young subject in whom the thymus still exists and is well
developed. He has never met with profuse hemorrhage or any serious compiica-

1883.]

Surgery.

273

tion in performing the superior operation; and he cannot understand why the
inferior method should be preferred in operating on young subjects of croup or
diphtheria.

The administration of chloroform during tracheotomy- is recommended in all
cases, save those in which there is intense asphyxia. No disadvantage, it is
stated, ever attends the use of this anaesthetic in favourable cases ; on the con-
trary, when the patient is well under its influence, the breathing becomes deeper
and less rapid, the cyanosis is diminished, and the operation can usually be
performed without undue haste.

In the after-treatment of his early cases of tracheotomy for croup or diphtheria,
Dr. Lindner trusted mainly to inhalations of lactic acid in a two-per-cent. solu-
tion. Of late, he has used only pure steam. The only way, it is now thought,
in which inhalations can act beneficially after tracheotomy, is by preventing an
accumulation of dry and firm secretion within and below the canula. That a
moist and warm inhalation can do this is not to be doubted ; but here the action
ends, as no inhalation, whether simple or medicated, can favour separation and
discharge of the false membrane. Continuous and forcible application of hot
steam is not free from danger, especially Avhen lactic acid or any conducting agent
has been added. Reference is made to the results of some experiments made by
Heidenhain to determine the cause of pneumonia after tracheotomy. In these
observations it was shown that, so long as the air respired by a tracheotomosed
animal is dry, no matter whether the temperature of this air be high or low, not
the slightest damage is done to the lung ; whilst on the other hand, air that is
moist and heated to 130°, or above this, will set up lobular pneumonia.

In some of his recent cases he has practised aspiration, which he regards as a
very efficacious means in the after-treatment of patients subjected to tracheotomy,
and of service when croup has extended below the bifurcation of the trachea,
and attacked the mucous membrane of the bronchi and their divisions. By this
treatment the air-passages may be cleared of accumulated secretion, which is the
cause, in many cases, of still impeded breathing after tracheotomy, and which
cannot be ejected spontaneously. Of nine cases of tracheotomy in which aspira-
tion was subsequently tried, eight were successful — a striking result, he points
out, as several of these were really severe cases, and five of the patients had
bronchial croup.

He regards apomorphia as a valuable agent in the after-treatment, if given in
sufficiently large doses. It excites an abundant watery secretion from the bron-
chial mucous membrane, and thought that it might thus favour separation and
removal of the false membrane. A favourable influence in this respect has, it
is stated, been exerted by apomorphia in several recent cases, in some of which
it was found necessary to perform tracheotomy.

An important point in the after-treatment in cases of tracheotomy is the
removal of the tube. This should be removed as soon as the air-passage is suffi-
ciently free ; but as to when this is really the case, there is likely to be much
difference of opinion amongst surgeons. In cases in which the patient is well
nursed and constantly watched, and surgical aid is close at hand, the tube may
be removed at an earlier period than in cases where such conditions do not exist.
Dr. Lindner states that when, after removal of the tube and temporary closing
of the wound, the patient breathes freely and can speak with a clear and strong
voice, there is no longer any necessity for the tube to be replaced.

Next to symptoms of general infection, pneumonia is the most frequent com-
plication after tracheotomy in cases of croup and diphtheria. A rise of tempera-
ture above 102° on the first or second day after the operation is to be regarded as
a bad sign. In cases of this kind the patient, according to Dr. Lindner's expe-
No. CLXXI July 1883. 18

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rience, rarely recovers. Impairment of deglutition through paralysis is regarded
as but a temporary result of diphtheria, and one needing no special treatment in
the majority of instances. Ulceration of the mucous membrane through pressure
of the tube may be avoided, Dr. Lindner thinks, by inserting an instrument
sufficiently large to occupy the whole calibre of the trachea. The shield of the
tube in ordinary use is considered to be too broad. — London Medical Record.
May 15, 1883.

Excision of the Abdominal Wall.

Prof. Sklifosovsky reports a case in which he excised nearly the whole left
half of the left anterior half of the abdominal wall on account of an enormous
sarcomatous growth. The patient, a?t. 24, had received a kick from a horse
about four years before, and six months after noticed a small lump, at the situa-
tion of the blow, which remained unchanged for three years, and then began to
grow very rapidly. When first seen it had attained the size of a man's head.
The tumour occupied the whole left side of the abdominal wall, from the edge
of the ribs to Poupart's ligament, and, at the level of the umbilicus and three
centimetres lower it involved, also, about four finger- breadths of the right side.
The circumference of the growth at its base was 81 centimetres (nearly 32
inches), the long diameter 40 centimetres (15.75 inches), the transverse, 39
centimetres (15.3 inches). The tumour was dense and heavy. The integuments
over it were movable, and traversed by numerous dilated veins. The patient's
general health was excellent.

On November 10, the operation was performed (under the strictest antiseptic
precautions). It commenced by a vertical incision along the linea alba, from the
end of the ensiform cartilage to the pubes, and by an arched incision along the left
costal border. After dissection of the integuments, it was found that the tumour
encroached. on all the muscular layers and the parietal peritoneum. Accordingly,
the next;step consisted in four incisions through the whole thickness of the abdo-
minal walls, namely : 1. An internal vertical one along the whole linea alba, with
deviation to the right in the degenerated portion of the umbilical region ; 2. an
upper transverse incision along the costal edge ; 3. a lower transverse, carried a
finger-breadth above Poupart's ligament; and 4. an external vertical incision
along the left axillary line, from the ribs to the crest of the ilium. The removal
of the excised parts left a formidable defect, through which there were seen,
fully exposed, the stomach, omentum, bowels, and a considerable part of the
liver. After cleansing the abdominal cavity, the viscera were covered by the
integumental flap, and two thick drainage-tubes, each 1 0 centimetres long, were
introduced, one near the umbilicus, another above the pubes. The wound was
covered by Lister' s> dressing, over which were placed several large pads of wad-
ding, in order to secure considerable pressure on the anterior abdominal wall.
The wound healed by the first intention. On November 11 and 12, the tem-
perature rose to 38.2° C. (100.75 F.), and then fell to the normal, to rise once
more to 38.0° C. (nearly 102° F.) on the 24th. The second elevation coincided
with the appearance of abundant suppuration under the flap near the navel.
During some days there were daily discharges of about three tablespoonfuls of
thick pus through the upper drainage-tube. On Dec. 3 the purulent discharge
stopped, and recovery since went on fairly.

On March 5, 1882, the patient left the author's clinic quite well, being fur-
nished with a suitable supporting apparatus made of poroplastic and two duly
curved steel springs. On inspection of the patient (with the apparatus off) lying
on her back, there was no bulging seen, except during coughing; but in the

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Surgery.

275

erect position, the left half of the abdominal wall was considerably bulged out-
ward, even during normal breathing.

The excised neoplasm, weighing 4100 grammes (9j pounds), proved to be a
spindle-celled sarcoma.

Prof. Sklifosovsky mentions that the first patient from whom he in 18 77 removed
a large sarcomatous growth, involving likewise the whole thickness of the abdo-
minal wall (see the Voyenno-Mediz JurnaL, July, 187 7), is still in excellent
health. She also wears a supporting apparatus, preventing eventration, and
feels quite comfortable. — London Med. Record, May 15, 1883.

Healing of Wounds of the Spleen.
A. Daxxexburg {St. Petersburg Inauy. Dissert., 1882) wounded, in various
ways, the spleen in fourteen dogs, killed the animals in periods varying from 24
hours to 108 days, and examined numerous specimens (taken from twenty-eight
wounds) microscopically. He sums up his results as follows: 1. Incisions into the
spleen are prone to rapid union ; some amount of gaping occurs only on the surface
of the organ. 2. Incisions into the pulp are prone to heal without suppuration. 3.
Suppuration of the splenic tissue, in the course of a wound, occurs only as a rare
exception. 4. Adhesion of the splenic capsule to the omentum, which develops
very rapidly, is one of the conditions leading to healing of wounds of the spleen.
5. Perforating wounds heal slowly, and always through development of granula-
tion-tissue. 6. Punctured wounds heal by the first intention. 7. Amputation-
wounds of the spleen heal by its adhesion to the omentum, resulting from the
formation of connective tissue between the parts. 8. In the formation of a scar,
both the proliferating elements of the splenic pulp and the epithelioid elements
of the reticulum take part. 9. Hypertrophy of the subserous layer of the cap-
sule depends on the proliferation of cells of connective-tissue. 10. There is pro-
ceeding an extremely active proliferation of capsular epithelioid tissue around the
edges of a wound 1 1 . There is proceeding a complete regeneration of the epithe-
lioid covering on the surface of a cicatrix left by a wound. 12. Under certain
conditions, common epithelioid cells may undergo transformation into cylindrical
and cuboid epithelioid elements. — London Med. Record, May 15, 1883.

A Case of Nephrectomy for Rupture of the Kidney where Lateral Cystotomy was
also subsequently performed for the Relief of Cystitis caused by Retained
Blood-Clots.

Dr. Henry G. Rowdox reported, at a late meeting of the Royal Medical
and Chirurgical Society {British Med. Journal, May 26, 1883), the following
case of this : —

Charles M., aged 12, was admitted into the Liverpool Infirmary for Children
on December 7, 1882. The previous day he had fallen into a stone basement, a
distance of about eight feet. On admission he was found to be passing blood in
his urine. He complained of some pain in his right side. The only other evi-
dence of an injury was a small bruise-mark over the crest of the ilium. The
diagnosis was that rupture of the right kidney had been caused bv the 'injury.
The hasmaturia for the first few days diminished, but it subsequently increased,
and was followed by acute cystitis. With the object of preventing blood from
entering the bladder, on the seventeenth day after the injury, the injured kidney
was removed by a lumbar incision, and then it was found to have been torn nearly
completely across. Relief followed the operation. Subsequently, symptoms of
acute cystitis again showed themselves. On the twenty-first day after the injury,

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and four days after the nephrectomy, lateral cystotomy was performed, when
fetid clots were removed, and a free drain of the urine was established. Relief
was afforded by the cystotomy so far as the symptoms directly traceable to the
bladder were concerned. The patient died on the fortieth day after the injury.
The cause of death appeared to have been pyelitis and circumscribed suppuration
of the left kidney, lesions probably traceable to an extension of the cystitis which
had been occasioned, partly by the presence of decomposing clots, and partly by
attacks of retention of urine. It was suggested that, if cystotomy had been per-
formed earlier, the latter consequences might have been averted.

Case of Excision of an Enlarged Cancerous Kidney.

Sir Spencer Wells, at the same meeting, narrated the case of a gentleman,
aged 58, whose left kidney he removed last December. It measured six inches
by four, and was the seat of the soft cancer. The patient died on the fifth day.
The operative procedure was described, and the author urged the importance of
uniting, in all cases of nephrectomy by abdominal section, not only the divided
peritoneal coat of the anterior abdominal wall, but also the divided peritoneal
covering of the kidney. In this case he was content with letting the two edges
fall together, and he thought that blood or serum exuding from the tissues behind
the peritoneum might have passed into the peritoneal cavity, or that some portion
of intestine might have adhered there. This might have been prevented by a
few sutures. He had not seen this detail in the operative proceeding referred to
in any previously recorded case of nephrectomy. — British Med. Journal, May
26, 1883.

Nephrectomy.

The narrative of the preceding cases gave rise to a very interesting discussion
at the Royal Medical and Chirurgical Society's meeting of May 22, 1883.

Dr. Dickinson expressed as a physician, his sense of the great debt of grati-
tude which was due to the surgeons who had brought stone in the kidney within
the list of curable diseases. As to the excision of tumours in the kidney, there
was more to be said. These were chiefly sarcomata of a very malignant type.
He had examined the post-moi'tem records of 19 cases, and found one point
prominent, namely, that there were secondary growths in all of them but three.
That showed their malignancy ; and he was, on the whole, against their excision,
for it was impossible to estimate them until they were far advanced, and then an
operation was only rendered justifiable by some such accident as hemorrhage.
Sir Spencer Wells's case, he submitted, was not explained by the post-mortem
examination. The blood which was so freely passed could not have come from
the kidney which was excised, for the malignant kidney did not bleed till it had
fungated and broken through the capsule, which had not happened in the kidney
which had been cut out. The blood, he was inclined to think, must have come
from the remaining kidney.

Mr. Barwell recommended a lumbar incision for removal, whenever it was
practicable, but remarked that the rib was, in many people, too near to the crest
of the ilium to allow of this. He agreed with Sir Spencer AVells's suggestions as
to sewing up the peritoneal covering of the kidney when an abdominal opening
had been made, but wished to take a further step in such cases, and to drain
through the loin the cavity behind the peritoneum, where there might be bleed-
ing or suppuration.

Mr. Lawson Tait took objection to Dr. Dickinson's opinion against excision

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Surgery.

277

of the renal tumours, on the ground that a diagnosis of malignant disease was often
impossible. He believed that they were all malignant in patients under lifteen,
and again almost all at an advanced age ; but such a case as Sir Spencer Wells's,
he thought, might have been one of hydatids. An abdominal incision in front
was advisable, as securing an opportunity of investigating the state of the kidney
which it was proposed to leave behind in cases of nephrectomy. The history of
Dr. Rawdon's case led to a suggestion, made after the event, that it would have
been desirable to open the bladder first to ascertain the origin of the bleeding,
and then, if the urine had continued to show blood, to make an incision for the
kidney.

Mr. Knowsley Thornton was sorry to admit that he had been unable to
throw adequate light on his own case. (See p. 293.) He was inclined to think
that the origin of the disease had been in the obstruction of both ureters in the
very early pregnancy of his patient (aged 15), and the formation thereby of a
sacculated kidney. In comparing the operations of nephrectomy and nephrotomy,
he was inclined to prefer the former, as giving a better chance ; and allowing, if
performed from the front, of some evidence being taken as to the state of the
other kidney, which would have been very important in such a ease as Mr.
Doran's. He could not agree with Sir Spencer Wells's suggestion as to the
sewing up of the peritoneal covering of the kidney, to prevent fluid getting into
the perineum • for he thought that, if a fluid was aseptic and free from putridity,
the peritoneum was the best tissue to absorb it. He felt, with Mr. Tait, the
difficulty of diagnosing the malignancy of the renal tumour to be dealt with. One
kidney, which he had excised, and which he showed as a specimen, was a case of
alveolar sarcoma, which would certainly not recur soon. In another case, he had
been so convinced of the malignant character of the growth by secondary deposits,
that he had refused to operate ; and, in some doubtful cases, he thought an ex-
ploratory operation would be justifiable. In a case in the country, he had come
to the conclusion that excision would be the best treatment, had obtained the
patient's consent, and arranged the operation. A clergyman, however, stepped
in and imposed his veto, under spiritual penalties on the patient, and the man
died without operation. After death, a non- malignant sarcoma of the kidney
was found, which could have been easily removed by operation. Mr. Tait had
expressed doubts as to whether a diagnosis of fresh bleeding from the kidney, or
discoloration of the urine by blood-clots in the bladder, could be made in Dr.
Rawdon's case ; but he thought an examination of the urine would have very
readily settled that. In conclusion, after having himself performed nephrotomy
in three cases, and nephrectomy in four (two by median incision, two by Langen-
buch's incision), he preferred the nephrectomy by abdominal incision.

Sir Spencer Wells said he very heartily agreed with what Dr. Dickinson
had said in some points ; but he thought the difficulty of diagnosis of malignant
renal tumours was greater than Dr. Dickinson had estimated. For instance, one
of the most distinguished physicians in the world had thought the tumour in the
case he had brought forward to-night was splenic. Against its malignancy, he
had the long duration of the tumour — for several years at least — and the absence
of evidence of any secondary deposits ; and, even if he had thought it to be
certainly malignant, he was inclined to think he ought to have removed it ; for
the patient was bleeding to death before his eyes, and it was a surgeon's duty to
stop that. In another case of tumour of an undescended testis, which was pro-
bably malignant, he decided to remove it, after consultation with Sir James
Paget, as he certainly should have removed it if it had been in the scrotum. He
was much obliged to Mr. Bar well for his suggestion of "draining" the cavity
behind the kidney ; and should be inclined to adopt it, keeping at the same time

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to his first idea of carefully sewing up the peritoneal covering of the kidnev.
Mr. Thornton's success in attacking kidney diseases through the abdomen had
first led him to attempt such an operation ; but many more facts were still neces-
sary before the value of the various methods proposed could be fairly estimated.

Dr. Southey suggested that a physical exploration of the kidney to be left in
the abdomen might be practically avoided by an estimation of the amount of urea
passed ; for from a normal amount of urea, a normal amount of secreting kidney-
tissue might be inferred.

Mr. Barker pointed out that a foreign observer had come to a conclusion
opposite to Dr. Dickinson's, as to the great malignancy of renal growths; for,
out of one hundred and thirty cases, he had found few instances of secondarv
tumours. In a cancerous kidney he had himself excised, he had only found one
or two traces of recurrent tumour in the lung, and none anywhere else. — British
Med. Journal, May 26, 1883.

Resection of the Intestine.

Prof. Edward yon Wahl, of the Dorpat Hospital, has recently published
in the St. Petersburger Medicinische Wochenschrift, two highly interesting cases
of resection of the intestine.

Three years ago, Dr. von Wahl operated on a man, aged 47, for strangulated
inguinal hernia. The intestine involved in the rupture was found to be partially
gangrenous ; the healthy portion on each side of the slough was, therefore, sewn
to the edge of the external wound, and the gangrenous segment was cut away. An
artificial anus was thus established. Six weeks later, in order to cure this com-
plication, two inches and a half of the intestine around the abnormal opening
were resected, and the edges of the gut above and below the seat of excision were
united by a single row of fine catgut sutures. The portion ot intestine that was
excised proved to be part of the transverse colon. Death, preceded by symptoms
of peritonitis, followed on the third day. At the necropsy, it was found that two
of the sutures had become loose, allowing extravasation of feces.

Last October, Dr. von Wahl had occasion to perform excision of the intestine
under more unfavourable circumstances. In removing a dermoid ovarian cyst
from a woman, aged 26, a portion of the ascending colon was found to be inti-
mately adherent to its surface. As the walls of the tumour, especially along the
line of adhesion, were undergoing malignant degeneration, Dr. von Wahl did not
consider it justifiable to merely separate the adherent intestine from the cyst,
but determined upon performing excision. The ascending colon lay deep in the
think, owing to the shortness of the meso-colon. The pedicle of the tumour was
first ligatured, and the omentum was separated from the tumour, which had no
pelvic adhesions. A clamp-forceps was then applied to the colon on each side
of the adherent part, the teeth being guarded by strips of India-rubber sheeting.
The adherent portion, four inches and a half in length, was now cut away, and
afterwards set free from the meso-colon. This last part of the operation was
rendered difficult by the great size of the vessels in the peritoneal fold ; but, by
a careful arrangement of sponges over the adjacent viscera and peritoneum, no
blood escaped into the peritoneal cavity. The ovarian tumour was then cut away.
A double row of carbolized silk-threads was now passed through the cut edges of
the colon. The first row, consisting of thirteen sutures, transfixed the serous and
muscular coats. The second or higher row, including ten sutures, passed only
through the serous coat. Apposition of the cut edges of the colon was found to
be perfect. The patient made a rapid recovery, a free motion being passed on
the eighth day. Unfortunately, a month after the operation, the patient began

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Surgery.

279

to complain of symptoms which led Dr. von Wahl to believe that the malignant
disease of the ovary had recurred in other abdominal organs.

It is clear that, in a case of this kind, excision does not present the difficulties
which are encountered when the operation is performed for the relief of chronic
obstruction, or the removal of a malignant segment of intestine. Dr. von Wahl
found no difficulty in securing apposition of the cut edges of the upper and lower
ends of the intestine, after that the sutures had been introduced, for there was no
contraction of the inferior nor dilatation of the superior portion of the severed
ascending colon, as seen in cases of stricture. Hence the clamps, applied in the
simple manner above described, proved sufficient for the operator's purpose,
without the application of the ingenious contrivance introduced by Mr. Treves,
and exhibited at a meeting, last December, of the Royal Medical and Chirurgical
Society ; yet, even in this case, the use of the India-rubber dilating bag would
have greatly facilitated the application of the sutures. — British Med. Journal,
May 26, 1883.

Abdominal Tumour consisting of Hair.

At the Twelfth Congress of the German Surgical Society Prof. Schonborn
exhibited a tumour, composed entirely of hair, which he had removed from the
stomach of a chlorotic and scoliotic young girl, who had been annoyed for three
years by gastric troubles. The diagnosis, when first examined, seemed to rest
between tumour of the spleen, omental tumour, and floating kidney. The
tumour, the situation of which was not constant, was situated in the left half of
the abdomen, and was of a kidney shape so far as could be determined through
the abdominal walls. Laparotomy was performed, and the tumour found in the
stomach itself. It had somewhat the shape of a contracted stomach, measuring
three inches along its greater curvature, and was of the appearance of the col-
lections of hair sometimes found in the abdominal cavities of cattle. During the
convalescence the patient admitted that she had been in the habit of biting off
the ends of her hair for several years. Prof. Schonborn has found seven similar
cases recorded in literature, the first being in 1 7 77. Contrary to the opinion of
Cloquet, that this only occurs in persons mentally diseased, Schonborn states that
none of the seven cases were mentally affected. The true diagnosis was not
reached in any of these cases, and they all died, either of peritonitis or excessive
vomiting, and one of hasmatemesis In one case the tumour, taken from the
intestine, was twenty inches long, and was carried for twenty years.

In the discussion elicited by this paper Prof. Ivuster said that the diagnosis of
floating kidney might have been excluded as, under an anaesthetic, the left kidney
can be distinctly felt below the twelfth rib, and the right also, though not so dis-
tinctly as the left.— Berliner Klin. Woch., April 23, 1883.

Fatal Hemorrhage from Ncecus of the Rectum.

At the meeting of the Royal Medical and Chirurgical Society, on April 10,
Mr. Arthur E. J. Barker offered this case for speical consideration on the
following grounds : I, On account of its rarity ; no similar case being known to
the author after careful search. 2. On account of the gravity of the condition in
this special instance, in which, in a particularly strong and healthy adult, slow
death from bleeding was the result. All the symptoms usually met with in those
dying of loss of blood appeared to be present here. Beyond these, there were
few special symptoms noticed as dependent on the condition. The patient, Avhose
earliest symptoms was an attack of diarrhoea accompanied by great loss of blood,

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usually suffered from constipation, and was obliged to strain much during defe-
cation. Sometimes, however, lie had intervals of diarrhoea, always with great loss
of blood, and felt no pain and lost no flesh, and there was no particular discharge
from the rectum except during the attacks of bleeding. 3. Because a diagnosis
of the condition was made by inspection of the rectum with a strong light. This
was thrown up the bowel by a forehead mirror from a powerful lamp, and through
a large vaginal speculum, which could always be introduced under chloroform.
The treatment suitable to such cases was a point that might be usefully discussed.
By this inspection, the mucous membrane of the bowel was seen to be marked by
smooth longitudinal folds, mottled with a peculiar purplish tint. On these pur-
plish folds were three shallow ulcers, whence blood tlowed freely. The patient
gradually sank, in spite of various remedies, and Sied from loss of blood. After
death, the wall of the rectum was found to be much thickened in the lower four
inches and a half of its length by na'void growth in its walls, on the ruga? of which
were the three shallow ulcers before described. The body in other respects was
healthy and well developed, but almost free of blood.

Mr. Howard Marsh related the history of an essentially similar condition in a
girl aged ten, under his care at the Children's Hospital in Great Ormond Street.
She had been subject to attacks of hemorrhage from the bowel from the time she
was two years old. The)' had occurred at first at intervals of about a year, but
after a time had grown more frequent, coming on about every month. The
amount of blood passed varied from a teaspoonful to a teacupful. AVhilst under
his care, he had himself witnessed two or three hemorrhages of the larger amount.
The symptoms of the case undoubtedly pointed to a naevus ; and on examination
of the rectum with a speculum, he found a naevus encircling nearly the whole of
the bowel close to the border of the anus, and reaching about an inch and a half
up the rectum. The aspect of the growth left no doubt as to its nature. Treat-
ment with Paquelin's cautery was found effectually to arrest the hemorrhage for
a time, but it was impossible to use such treatment over any large surface, for
fear of producing a stricture of the anus. The position of the growth afforded no
chance for ligature. The child was three times in the hospital, and was dis-
charged finally with its hemorrhage greatly relieved, but not entirely cured. —
Med. Times and Gaz., April 28, 1883.

Controlling Hemorrhage in Amputation at the Hip- Joint.

Mr. Jordan Lloyd describes a new method which he has several times em-
ployed for controlling hemorrhage in amputations and excisions at the hip-joint.
It is an adaptation of Esmarch's method. The limb is first elevated and stripped
of blood. A strip of black India-rubber bandage about two yards long is then
doubled and passed between the thighs, its centre lying between the tuber ischii
of the side to be operated on and the anus. A common calico thigh roller must
next be laid lengthways over the external iliac artery. The ends of the rubber
are now to be firmly and steadily drawn in a direction upward and outward,
one in front and one behind, to a point above the centre of the iliac crest of the
same side. They must be pulled tight enough to check pulsation in the femoral
artery. The front part of the band passing across the compress occludes the
external iliac and runs parallel to and above Poupart's ligament. The back half
of the band runs across the great sacro-sciatic notch, and, by compressing the
vessels passing through it, prevents bleeding from the branches of the internal
iliac artery. The ends of the bandage thus tightened must be held by the hand
of an assistant placed just above the centre of the iliac crest, the back of the
hand being against the surface of the patient's body. It is a good plan to pass

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Surgery.

281

the elastic over a slip of wood held in the palm of the hand, so as to diminish the
pain attending the prolonged pressure of the rubber bandage. In this way an
elastic tourniquet is made to encircle one of the innominate bones ; checking the
whole blood-supply to the lower extremity. The elastic bandage may be secured
above the iliac crest in the usual manner with tapes, and may be prevented from
slipping downward by being held with a common roller tied securely over the
opposite shoulder, Experience has shown, however, that no mechanical means
answer so well as the hand of a trusty assistant. When the band is once pro-
perly adjusted, the assistant has only to take care that it does not slip away from
the compress or over the tuber ischii. The former is prevented by securing pad
and tourniquet together with a stout safety pin ; and the latter by keeping the
securing hand well above the iliac crest, or even more safely by looping a tape
beneath the elastic near the tuber ischii, passing it behind under the sacrum and
having it held in that position. The solid rubber tourniquet may be used instead
of this bandage. I prefer, however, the bandage. The soft parts are less
damaged by reason of its greater breadth, and it is less likely to roll off the
compress placed over the external iliac.

The ligature, being altogether above the limb, is out of the way of the surgeon
in any operation at or about the hip-joint. The great trochanter is fully exposed ;
the hip being free upward as far as the iliac crest, and inward to the perineum.

The bandage has the following advantages over Davy's lever: 1. The sim-
plicity and certainty of its application ; no previous experience being necessary
to compress the vessels, there is no possibility of going wrong. 2 The security
with which the vessels are controlled, regardless of the movements of the patient
or manipulations of the operator. 3. The freedom from danger of injury to the
rectum or abdominal contents. (Davy related a case at a recent meeting of the
London Clinical Society, in which he himself had wounded the rectum with his
lever; the patient dying on the following day of peritonitis.) 4. Its applica-
bility to cases in which the rectal lever could not be employed, as in strictures of
the bowel, intra-pelvic growths, and arterial abnormalities. 5. It requires no
special apparatus. — Lancet, May 26, 1883.

Ligation of large Arteries by the Application of two Ligatures and Division of
the Vessel between them.

Mr. W. J. Walsh am has recently tied the femoral artery three times in this
manner. In each instance, two ligatures were applied, a liitle less than a half an
inch apart, and the artery completely divided between them. The ligatures used
were kangaroo-tail tendon ; the wounds did well ; the operations were performed
strictly antiseptically ; and in each instance the patient made a good recovery.

In the discussions that have been raised from time to time at the medical socie-
ties, and at the last meeting of the British Medical Association, on the value of
different kinds of ligature, carbolized and chromicized catgut, ox aorta, whale
tendon, carbolized silk, carbolized nerve, kangaroo-tail tendon, etc., it has always
seemed to me that a very important point in accounting for failure has been lost
sight of. Want of success has nearly always been attributed to the fault of the
ligature used, and little or no account has been taken of the way in which it was
applied. It is true that different opinions have been expressed as to whether the
ligature should be tied tightly or loosely ; whether or not it should be our aim to
divide the internal and middle coats of the artery ; or whether the mere contact
of the ligature with the vessel is not sufficient to accomplish our purpose. The
point to which I would refer as influencing the result of the operation is the
amount of separation of its sheath that the artery has been subjected to in passing

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[July

the ligature. That failure, in some instances, has been due to the softening or
giving way of the material used, there can, of course, be no question ; but I can-
not help thinking that too free a separation of the sheath in passing the ligature
may have had, in many instances, more to do with the want of success titan the
kind of ligature chosen. As the vitality of an artery depends in great measure
upon the blood-supply that it receives from its sheath, it is easily conceivable how
very little more or less separation may determine the success or failure of the
ligature. No point, I suppose, is more strongly insisted upon in the works of
surgery than the necessity of exposing as little of the vessel in its long axis as
possible.

If two ligatures be applied, and the vessel divided between them, all risk of too
free a separation of the sheath is absolutely avoided, as one ligature can be applied
at the spot where the sheath is separated above, and the other where the. sheath is
separated below. After the vessel is divided, each cut end retraets, drawing the
respective ligature well into the sheath, thus leaving the blood-supply of no por-
tion of the vessel on the proximal and distal side of the upper and lower ligatures
respectively in any way interfered with. The artery is thus placed under very
nearly the same conditions as one which has been ligatured in a stump, and ex-
actly under the conditions as one the ends of which have been secured in a wound,
and from such secondary hemorrhage is very rare. Indeed, I am not aware that,
after the two ends of a divided vessel have thus been tied in a wound, hemor-
rhage, except from the slipping of a ligature, has ever occurred.

The normal longitudinal tension of the vessels constitutes another, and I believe
not inconsiderable, source of danger in ligaturing an artery in its continuity. A
transverse wound of an artery, as first pointed out by Mr. Savory, in consequence
of this elastic tension, assumes a diamond shape. Should any part of tin; liga-
ture cut through the vessel before it has become permanently occluded, this
tension, by causing such a cut in the vessel to gape, thereby disturbing the con-
nection of any internal clot that may have formed, or adhesions of the coats
that may have taken place, must tend to the production ol secondary bleeding.
In a case of secondary hemorrhage under the late Mr. Callender, on cutting
down at the seat of ligature to secure the bleeding points, the hemorrhage was
clearly seen to be due to such a cause. The vessel, which had been secured by
a catgut ligature, had given way opposite the knot (which itself was intact), and
a gaping wound one-tenth of an inch wide existed in the walls of the vessel. By
applying two ligatures, and dividing the vessel between them, all tension is taken
off, and both ends are placed in a state of rest — the most favourable condition for
healing. — Brit. Med. Joum., April 7, 1883.

Deligation of the .Common Carotid.

Weljaminow, of St. Petersburg, has collected thirty-three cases (DcvtscJie
Med. Zeit., No. 40) in which the common carotid was tied. The artery was
ligatured four times for hemorrhage due to wounds, once for angioma, fifteen
times for malignant tumour, for or during operations on the head eight times,
four times for operations about the neck, and once for aneurism (Brasdor- War-
drop's method, i. e., ligature on distal side of sac). The right artery was tied
eighteen times, the left fourteen (sic) ; eighteen times in men, fifteen in women.
The age of many of the patients (fourteen) was betwreen fifty and sixty ; in two
cases, however, the age was seventy-two, and in one only twenty-one months.
These last three patients got over the operation very well. The wound healed
by first intention sixteen times. Erysipelas and secondary hemorrhage were each
observed once only. To prevent the occurrence of cerebral disturbance the artery

1883.]

Surgery.

283

was systematically compressed some days before ligature. Eleven out of the
thirty-three patients died soon after the deligation (33.3 per cent.), but for sta-
tistical purposes only 25 (? 23) are available, of which one died, giving a mor-
tality of 4 per cent. The author has collected yet other twenty cases, all treated
antiseptically, and all recovered. In conclusion, the writer dilates on the impor-
tance of a double ligature, between which the artery is divided. — Med. Times
and Gaz , Oct. 28, 1882. _

Nerve Stretching.

Dr. Cecchekelli (Lo Sperimentale, 1882) contributes a very complete and
interesting summary of the literature and results of this operation. He divides
his subject into two parts. In the first he collects the anatomical and physiolo-
gical facts, and in the second he describes the operation, the indications for its
employment, and the results so far obtained.

As to how much the nerve is to be stretched, he cites many experiments in
animals, and gives Frombetta's careful experiments as to the weight the different
nerves removed from the body are able to sustain. He does not think these ex-
periments of much practical good ; the surgeon must be rather guided by the
sensation of greater or less elasticity and resistance which he experiences. The
anatomical lesions are of the perineurium, capillary vessels, and nerve-tubes,
causing exhaustion and degeneration. The physiological effects are interruption
of the ascending sensory current and continuance of the descending motor cur-
rent; hence, perhaps, the frequent failure of nerve-stretching in tetanus (Artaud
and Gilson). Quinquaud observed that in the stretching of the sciatic nerve, for
example, there was also anaesthesia of the area innervated by the sciatic of the
opposite side, and sometimes also in that of the crurals of the two sides. On
stretching the right sciatic, there was anaesthesia of the right limb posteriorly ;
stretching shortly afterward the left sciatic, there were anaesthesia of the left
limb posteriorly, and return of sensibility in the right limb. "When a nerve
is stretched, the effect is therefore transmitted to the posterior part of the me-
dullary axis. Labord and Debove divided the spinal cord and caused epilepti-
form movements : they stretched the sciatic nerve, and the movements were
suddenly diminished. Wiet and Marcus found that when the pneumogastrie
was stretched, the movements of the heart were accelerated.

The conclusions from these facts, and, as corollary, that the stretching of a
nerve produces ecchymosis under the perineurium, rupture of the nervous fibres,
and ascending degeneration, as in partial section of a nerve, would be, that
nerve-stretching causes loss of sensibility ; that the sensory ascending current
disappears, while the motor or descending current is preserved ; that it affects
the centres and may cause trophic disturbances with persistence or not of anaes-
thesia. Moderate stretching produces anaesthesia in the territory of the nerve
without loss of motility ; violent stretching causes prolonged and persistent anaes-
thesia with constant alterations of motility and nutrition. The frequency of
functional disturbances of parts far from the seat of operation proves that the
spinal cord is influenced by the stretching of certain nerves (the sciatic and bra-
chial plexus) ; for lesser nerves and for cords farther from the medulla, further
researches are necessary. Notwithstanding the microscopical lesions which
have been observed, the manner in which the distension acts is not yet determined
(Chauvel).

In the second part, Dr. Ceccherelli describes the operation, He recommends
the incision to be made as near the supposed seat of irritation as possible, the
stretching to be made in the centrifugal and centripetal directions, and not
excessive, with the finger or blunt hook. With the finger the surgeon is beet

284

Progress of the Medical Sciences.

able to judge, by the elasticity and resistance, of the force required. Nerve-
sferetching has been tried in many diseases, peripheral neuralgia, spasmodic affec-
tions, epilepsy, paralysis, tetanus, ataxy, anaesthesia in leprosy, etc. The author
collects 252 cases, the results being 37 deaths, 16 failures, 34 cases improved,
156 cures, and 9 in which the result is not stated. Nerve-stretching has been
most successful in peripheral neuralgia ; out of 99 cases 74 were cured, 12 im-
proved, 7 doubtful, and only 6 failures. In contractures, 14 cases, there were
12 cures; in facial tic, 7 cases, 6 cures; in traumatic spasms, 12 cases, 10 cure*; ;
in peripheral paralysis, 34 cases, all successful. Although experiment proves
that nerve-stretching influences the spinal cord, in disease of central origin its
effects are unsatisfactory. In 36 cases there were 5 cures, 16 improved, 7 fail-
ures, 8 deaths ; epilepsy, 4 cases, 1 delayed success, 3 improved ; tetanus, 45
cases ; 14 successful, almost, if not all, cases of partial tetanus only ; 2 results
not stated, 29 deaths. In ataxy it has been most unsuccessful. Langenbuch
gives 16 cases with 6 cured; but Bernhardt and Westphal say they have never
seen a case improved or cured. Debove thinks the '' lightning" pains maybe
relieved by it. Yizioli also thinks that mechanical distension of the hyperaes-
thetic nerves, inducing a changed position of nervous molecules, may modify the
molecular grouping by which excitability was exalted, and the return to the
normal state may ensue. The author concludes that in all cases in which the
lesion is peripheral the effect is certain, almost without danger, and more prompt
than any other mode of treatment. In central lesions, all means fail; in extreme
ills, extreme remedies ; therefore it is only to be tried in extreme cases. If by
it we could promise improvement or diminution of any one of the grave symp-
toms, it would be the surgeon's duty to operate, but as yet we cannot say even
that much. — London Medical Record, April 15, 1883.

Su b pe Host eal Rejections.
The following resume is given at the conclusion of an original memoir by Pro-
fessor Oilier on subperiosteal disarticulations and amputations (Recue de Chi-
rurgie, Nos. 7-12).

1. Amputations practised with a periosteal flap or cuff (manchette), though
they have not always furnished results differing very much from those of ordinary
amputations, are in these days of antiseptic dressings attended with results more
conformable to such as surgeons have been led by experiment to expect. They
favour immediate union, but in young subjects they are liable in certain regions
to result in inconvenient osteophyte formations. In adults, subperiosteal ampu-
tation is not likely to cause this unsatisfactory result.

2. Subperiosteal amputation in the continuity of a bone, with preservation of
the whole of the periosteal sheath and of the peripheral tissues beyond the limits
of the section of the bone, gives rise in young subjects to the formation of an
osseous mass, which is very useful for maintaining the length and solidity of the
stump.

3. All disarticulations, with the exception of those practised for relapsing
neoplastic lesions (osteo-sarcoma, medullary cancer, etc.), ought to be performed
by the subperiosteal method. Traumatic lesions and gunshot wounds furnish the
most favourable conditions for the application of this operative method.

4. These disarticulations are to be practised on the same principles as those by
which we are guided in subperiosteal resections. The incisions practised in this
latter class of operations will serve in the disarticulation of most of the bones,
whether the surgeon amputate after having attempted to perform resection or
proceed at once to disarticulate.

1883.]

S urgery.

285

5. Subperiosteal disarticulations have great advantages over the older methods
of resection, with regard to the performance of the operation. In cases where,
for some reason or other, the surgeon cannot have recourse to artificial exsan-
guification, he can operate with but little loss of blood. The hemorrhage is
always less severe than in operations by the older method, in which large flaps
are formed and thick masses of soft parts cut through. In stripping away the
soft parts from the bone, the surgeon is able to preserve all the elements that
are useful for the constitution of a thick, well-padded, and even stump. In
infants and young subjects one may obtain, by preserving the periosteum, a new
and movable bone in the stump, and thus considerably improve the orthopaedic
result of the operation.

6. In subperiosteal disarticulations the wounds are limited by a fibrous mem-
brane, which circumscribes the injury and forms a barrier against diffuse inflam-
mations. All other things being equal, they are less dangerous than ordinary
amputations, which leave a more extensive and irregular wound, since in sub-
periosteal disarticulations the flap is formed directly from'" the muscular mass,
and the bone can be carefully dissected out ; whilst in the older methods of
amputation the muscular spaces are freely opened, and there is a risk of cutting
vessels and nerves longitudinally. Moreover, the surgeon, in this latter class of
operations, sacrifices healthy tissues which would have served to form part of the
stump.

7. Of almost impossible application before the discovery of surgical anaesthesia,
in consequence of the time they require and of the pain which they would cause
to the patient, subperiosteal disarticulations cannot be met with any objection at
the present day, since the question of the duration of an operation has become
one of quite secondary importance.

8. In subperiosteal disarticulations, only a bistoury and raspatory are required,
and a small knife, which will be found useful in the last stage of the operation
(section of the soft parts). The use of large knives should be abandoned in
such operations.

9. Although the longitudinal incisions of subperiosteal resections may serve in
general manner for subperiosteal disarticulations, it will be found advisable to
modify these to a slight .extent in the latter operations. The bone should be
approached in the readiest and most direct way, without any attempt being
made, as in resections, to maintain the integrity of the muscles surrounding the
articulation.

10. A circular operation is most suitable in performing subperiosteal resection.
The wound is less extensive, and the bleeding surface is reduced to the surface
of transverse section of the flesh and to the surface of the periosteal sheath.

It. If, as in cases of neoplastic lesions of osseous or periosteal origin, it be
found necessary to abstain from performing subperiosteal resection, the surgeon
should have recourse to periosteal resection ; that is to say, he should, in sepa-
rating the soft parts from the bone, follow the external aspect of the periosteum.
In cases of malignant new growth, the knife should be applied as far as possible
from the bone, in order to guard against local relapse.

12. In the majority of subperiosteal disarticulations (shoulder, hip, elbow),
it is necessary to attack the joint as speedily as possible, in order to open the
capsule and displace the end of the long bone. This having been exposed and
stripped of its periosteum, the soft parts are to be completely divided. In other
regions (knee) it is better to separate the soft parts in the first place, and to cut
the flaps before disarticulation. — London Medical Record, April 15, 1883.

286

Progress of the Medical Sciences.

[July

Resection of the Wrist.

Dr. G. Xkpveu, after reviewing in a general way the operative, functional,
and therapeutic results of this operation, with a table of sixty cases, draws the
following conclusions: 1. Carpal, radio-carpal, and carpo-metacarpal resections
for pathological causes, only compromise life to a slight extent, especially when
treated antiseptically. 2. They sometimes give good results in that they sup-
press the local affections and preserve a useful member. 3. The completely
good results are only observed in one-fourth of the cases ; much more frequently
there is incomplete recovery, and very imperfect re-establishment of the func-
tions of the limb — in a word, operative and functional unsuecess. 4. The graver
complications are equally common. In some cases the operation is fatal directly
or indirectly ; in others it docs not arrest the local lesion, and amputation of the
forearm is necessary ; and in still other cases, though the result of the operation
seems to be good, the general health of the patient does not improve, and finally
the patient succumbs to tuberculosis. 5. From the point of view of definite and
complete cure, the curative power of resection of the wrist is feeble. 6. This
deficiency of curative power is due, in a measure, to the fact that the operation
is often performed under very unfavourable conditions ; the operation is contra-
indicated in cases of osteo-arthritis, and especially in tendinous and articular
synovitis. In these cases amputation should be performed at once ; it is contra-
indicated in old and phthisical persons, and should only be exceptionally per-
formed in cachectic scrofulous subjects. 7. To ameliorate the functional results
as little bone as possible should be removed, and the dorsal and palmar periosteo-
ligamentous structures should be preserved. 8 The operation should only be
performed after the other therapeutic resources have failed — immobilization,
compression, revulsion, drainage, prolonged antiseptic baths, etc. The combina-
tion of these, means gives excellent results when the constitutional state is so bad
as to forbid operative interference. Xo reference is had in these remarks to re-
sections for traumatism. — Revue de Chirurrjie, May, 1883.

Resection of the Knee.
Ollier, in an exhaustive paper on this subject, in which he gives details of
eight cases and his method of operating, draws the following conclusions: 1.
Antiseptic dressings have completely changed the indications and prognosis of
resection of the knee. While formerly it was wise and prudent to ignore
many of the indications for this operation in hospital practice, at present
it would be irrational to amputate the thigh in many cases in which resection
of the knee is applicable. 2. In infants, on account of the dangers of ulterior
increase of bone, the expectant method of treatment in suppuration of the
knee and the employment of more simple procedures than resection must still
be insisted on, as arthrotomy, articular abrasion, drainage, etc. In fact these
proceedings may be resorted to at all ages, but resection of the knee should be
preferred to amputation. Amputation should be performed in the grave forms
of tubercular arthritis. 3. The gravity of resection of the knee is no greater
to-day than is that of amputation of the thigh. The cases reported (by Oilier)
show that success is the rule in resection in the same conditions in which it was
formerly the exception ; and one should prefer amputation to resection, or vice
versa, on other grounds than the mere gravity of the operation. 4. Osseous
anchylosis should always be desired and sought for after amputation of the knee,
but in case this cannot be obtained, a solid articulation should be attempted. 5.
The subperiosteal method enables one to obtain this result. It accumulates about

1883.]

Ophthalmology and Otology.

287

the surfaces of the section, the tissues most favorable for ossification, and in case
there is non-union a museulo-ligamentous band is preserved completely encircling
the new joint — the bones, kept together by the passive resistance and the muscles,
play on each other with sufficient solidity. 6. It is difficult to appreciate, with
the data now in our possession, the value of resection of the knee in military
surgery. It may be at least presumed that we can obtain results just as good as
in civil surgery if proper care can be given to the wounded. 7. All the anterior
transverse incisions opening the joint may be used. It is necessary only to make
the incisions of less length than heretofore, as it is important to preserve the lateral
ligaments. An incision should be made on a level with the posterior border of the
condyles of the femur, and an incision on each side for drainage. 8. In chronic
suppuration of the joint it is generally necessary to remove the patella, preserving
its anterior periosteal coating. The patellar ligament is preserved by suture. 9.
In comminuted fractures of the articular extremities, longitudinal are preferable
to transverse incisions. The longitudinal, median, anterior incision, cutting off
longitudinally the patella and patellar ligament, facilitates the operation and pre-
serves all the elements for the re-establishment of a new joint, at the same time
favouring anchylosis, should that be desired. 10. In osseous anchylosis of the
knee subcondyloid osteo-clasis should be practised. It is especially applicable
in anchyloses of traumatic or rheumatic origin, when flexion cannot be per-
formed, or cannot be carried further than a right angle, and when there are no
deep cicatricial bands in the popliteal space. 11. Subcondyloid osteotomy or
resection are preferable where there i? reason to fear that vessels or nerves in-
volved in the cicatricial tissue may be wounded. In these cases total resection
of the condyloid enlargements should be practised if the cicatricial adhesions
are deep and many, and if flexion passes a right angle. 12. Resection of the
condyloid swelling is the only operation to be performed when there are signs of
osseous inflammation. In these cases when flexion goes beyond a right angle,
Ave should not be contented with taking out a wedge ; a trapezoidal fragment
should be taken out. This is the only way in which to bring in contact the sur-
faces of section without provoking painful traction, and dangerous to the circula-
tion of the limb. — Revue de Chirurgie, May, 1883.

OPHTHALMOLOGY AND OTOLOGY.

CMoroma.

Nearly fifty years ago, Billroth is said to have described a form of malig-
nant growth distinguished by a green discoloration, whence we derive the name
of chloroma or "green cancer" (Billroth). There can be no question that the
disease is of rare occurrence. In 1878, Huber (Archio der Heilkunde, xix.)
was able to collect only seven examples. The tumours are not cancerous in the
modern sense of the term, and so may best be described as chloro-sarcomata, or,
more simply, chloromata. Such tumours have been met with in connection with
bones [e. g., the skull), but perhaps the chief centres of the lymphoid tissue of
the body are the seats par excellence of tumours of a green colour, this anatomi-
cal system having become involved in a secondary manner, or even having been
the primary seat of disease.

As an apparent example of this, we shall describe the main features of an
interesting case recorded in Yirchow's Archiv for January, by Louis "YYaldstein

288

Progress of the Medical Sciences.

[July

A man, aged forty-four years, by occupation a labourer, suffered from a short
attack of "ague" many years before the commencement of his present illncgs.
Without any assignable cause the symptoms of marked progressive anaiinia set
in rather suddenly. Satifactory collateral evidence of the nature of the disease
was not forthcoming; the urine, however, was noted to be of a green colour,
and there was rather high persistent fever. On the twenty-fifth day of the illness
the patient complained of pain on percussion of the sternum, and later also of
some of the ribs. Gradual enlargement of the spleen and liver avms detected hy
the ordinary methods. A great increase in the number of the white cells of the
blood was first observed on the forty-first day of the illness ; repeated observa-
tions negatived the existence of leucoeythamiia before that date. Death followed
in three days, on the forty-fourth day of the malady. At the post-mortem ex-
amination, the mediastinal glands were found to be much enlarged and coloured
green ; the retro-peritoneal glands and those of the portal fissure were also stained
green. Although there were plugs of leucocytes in the hepatic capillaries, dis-
tinct areas of hyperplasia of the lymphatic tissues of the liver were not observed.
It will be remembered that some investigators regard the white areas in the
kidneys and liver of cases of leucoeythasmia as extravasations from the blood-
vessels. The spleen was enlarged, the Malpighian corpuscles being much over-
grown. The medulla of the bone was red, and in many places was of a greenish
hue. Wherever the chlorotic tint was seen, the microscope revealed either a
diffuse "coloration" or the pigment existed in granules in the protoplasm of
the cellular elements. The green tint has been severally described as apple-
green, gray-green, grass-green. The results of chemical analysis have been by
no means satisfactory. Huber thought the pigment was that of a fatty body,
Balfour regarded it as biliverdin, Dressier suggested its identity with the colour-
ing matter of greenish pus, whilst Dittrich has advanced the notion of its
dependence on putrefaction. Waldstein is inclined to believe the coloured pig-
ment was derived from the colouring matter of the blood, and he points to its
general presence in the morbid tissues and to its passage with the urine as
favouring his view. It is not at all improbable that every form of pigment
occurring in the human body may ultimately be traced to one original source,
viz., luemoglobin. — Lancet, April 21, 18<S3.

MIDWIFERY AND GYNAECOLOGY.

Treatment of Placenta Prozvia.

Dr. Hofmeier's conclusions (Zeitschrift f. Geb. unci Gyncek., 1882), and
methods claim our attention on account of the excellence of his results. His ex-
perience extended over forty-six cases, thirty-five of which were delivered in one
year, and thus offers an excellent chance to judge of the method carried out by him.
He first excludes from the forty-six cases three who were so far gone from hemor-
rhage when he arrived that there was no chance for any treatment. Of the re-
maining forty-three, in nineteen the situation of the placenta was central, in six-
teen lateral, and in eight marginal — a very large percentage of central placenta-
tions. The usual rule of treatment is to tampon until the cervix is sufficiently
dilated. This rule the author opposes. He scarcely ever uses a tampon, and as
to the cervix his rule is only to wait till clear symptoms of labour set in, i. e.,
either uterine contractions or funnel-shaped dilatation of the cervix. He then

1883.]

Midwifery and Gynaecology.

289

proceeds as actively and speedily as possible. This rule was followed in thirty-
seven of the forty-three cases, after unfavourable experience in other method!
with the rest. In nineteen cases the cervix was perfectly dilated, in eighteen
either entirely closed or with only a funnel-shaped dilatation. The earlier the
operation the more of necessity is the choice of it limited to the combined exter-
nal and vaginal version with one or two fingers, the Wigand-Braxton-Hicks
method. This was done in thirty cases, the foot was brought down in three
breech cases, three times internal version was performed, and once the forceps
applied. The combined turning was practised as long as possible, and the hand
introduced into the uterus only when absolutely necessary. The feet having been
guided to the os are seized, and by firm traction the buttocks effectually stop the
hemorrhage. In cases of central position of the placenta, the author r in spite of
all the arguments against it, is in favour of perforating the placenta, and bringing
the feet through. He did it in five cases, in three of which it was necessary on
account of haste, and in two of which the child was already dead. It gives the
mother the best chance, and the child's chance is by any method in such a case
extremely small. The rest of the delivery,, the author expressly states, should
be slowly accomplished. The condition of the child may modify this rule, but
even this must not make us increase the mother's risk. " The physician must
have the courage to let a doubtful child's life be lost in his hands, rather than-
subject the mother to increased danger. The child is to be delivered slowly."
Even so, the author's results were not bad as regards the children. Of thirty-
seven, seventeen were already dead ; of the twenty still living,, six died (three
premature, and three from perforation of the placenta).. Altogether,, sixty-three
per cent, died, and thirty-seven per cent, lived, which is up- to the usual standard.
The statistics as regards the mothers,, however,, are much better. The author
considers in them not only the immediate result, but the after course of the case.
In each case ergotin was given subcutaneously during extraction, and the uterus
was washed out afterward with a five per cent, solution of carbolic acid. Of the
thirty-seven patients treated by these rules, one died. She had been treated for
twenty-four hours by tampon, and the placenta was foul and offensive when the
delivery took place, and she died seventeen days after from phlegmon and phle-
bitis of the thigh. The author believes she would have surely been saved if ac-
tion had been prompter. This one case, out of thirty-seven, gives a mortality
rate of 2.7 per cent., which is far above any published rate, others having been
10 per cent., 16 per cent., and 40 percent. After hemorrhages occurred in some
cases, but none which could not be controlled with ergotin, ice, and hot-water
injections. Of the six cases treated at an earlier date, and by the waiting method,
one died ; two had a long severe lying-in ; four children were dead. Of the
whole forty-six cases, therefore, five died — 10.8 per cent. The author adds two
useful hints as to the situation of the placenta In nearly central situations, the
smaller portion is on the lateral side, which is more loosened from the cervix
lip. In placenta prsevia the proportion in favour, of the right side is about 11 to>
4. — Practitioner, May, 1883.

Treatment of Post-par turn Hemorrhage in Cases of Placenta Prcevia.
In cases of post-partum hemorrhage of placenta prsevia, and due to atony
of the uterine tissue at the point of placental insertion, Klotz advises the fol-
lowing procedure : The right hand is introduced into the vagina, and with the
left pressure is made upon the fundus through the abdominal wall, so that the
uterus, firmly compressed between the two hands, is antefiexed. The thumb of
the right hand is then introduced into the vagina, and occupies the angle formed
by the neck and body of the uterus, and presses on the tissues at this point. In.

No. CLXXI July 1883. 19

290

Progress of the Medical Sciences.

[July

this manner the whole lower part of the uterus is compressed, partly by its ante-
flexed position, partly also by the action of the hands, and especially by the
thumb of the right hand. Klotz has used this method in two cases. Pressure
was kept up for half an hour in one, and forty-five minutes in the other case : in
both cases the hemorrhage was arrested perfectly. — Bull. Gen. tie lite* rap ,
May 30, 1883.

Metr ia.

At the meeting of the Academy of Medicine in Ireland, on February 23d, Dr.
Atthill read a paper on metria (so-called puerperal fever). He said that our
knowledge of the various affections included by the Registrar-General under the
term metria, still far from perfect, had of late been steadily increasing. It was
now all but universally conceded (1) that there was no such single disease as
puerperal fever properly so-called, that is, a specific disease in the same sense as
scarlatina or smallpox ; (2) that inoculation and absorption of septic matter con-
veyed from without formed a not unfrequent cause of one form of metria, viz.,
puerperal septicaemia ; and (3) that puerperae frequently became self-inoculated
by poisonous material generated within their own bodies, either by the decompo-
sition of retained clots or shreds of membranes or placenta, the resulting fever
being by some called puerperal sapraemia, in contradistinction to septicaemia.
He held that the septicaemic form of metria could only be communicated from
one puerperal woman to another by the actual transfer of the pathogenic matter,
either by the hands of an attendant, or the nozzle of a syringe, sponges, napkins,
etc., but not by the medium of the air. To two points he drew special attention :
the frequent occurrence of metria in puerperal women preyed upon by remorse
or mental distress; and the occasional outbreak of a very fatal, infectious, and
essentially epidemic form of metria which, he believed, could not be due to septic
absorption. The influence of remorse and mental distress in predisposing to the
disease was well seen in the high mortality attending puerperality in women who
had been seduced ; and if such cases were excluded, he thought that the mortality
of the Rotunda Hospital would only amount to one-half its present rate. Here
fretting and a quickened pulse were the earliest symptoms of danger, a severe
form of metria manifesting itself after twenty-four hours. These cases of metria
were usually due to self-inoculation, the putrid matter finding a ready inlet be-
cause of the deficient post-partvm contraction of the uterus in such patients.
Occasional outbreaks of an epidemic and very infectious form of metria were
also known to occur, the disease spreading widely among the inmates of a hos-
pital. He could not accept Dr. Evory Kennedy's explanation of these outbreaks
as due to the aggregation of puerperal women, nor could he admit their septic
origin, since septic material was not communicable through the air. He held,
rather, that these outbreaks, occurring simultaneously with epidemics or other
zymotic fevers, were really examples of these zymotics, specially modified by the
physiological state of puerperal women. The infection of erysipelas could thus
induce an attack of infectious metria in a puerperal woman ; while, conversely,
such a form of metria could impart erysipelas to her offspring. In the summary,
scarlatina grafted on a puerpera might result in metria and not in scarlatina.
This infectious form of metria tending to assume an epidemic character, was,
therefore, to be considered as consisting of specially modified cases of the pre-
valent zymotic disease.

As strengthening this view, Dr. Atthill noticed the fact that, in his experience,
bronchitis or pneumonia occurring in a puerperal patient wyas likely to be com-
plicated by abdominal symptoms of the same kind as those which were seen in
puerperal septic fever. These views he exemplified by a history of such an epi-

1883.]

Midwifery arid Gynaecology.

291

demic of infectious fever, occurring in the Rotunda Hospital in August last, and
which, in the author's opinion, depended for its origin and infectious character
upon an imported case of typhoid fever in a puerperal patient. The outbreak
was completely stamped out by closing and thoroughly disinfecting the hospital
for a fortnight. The severe symptoms and rapidly fatal course of this epidemic
form of metria, differed essentially from the more insidious and less powerful
progress of puerperal septicaemia, on the characteristics of which he dwelt at
length, emphasizing the good prognostic import of a furred, as opposed to a
glazed and cracked tongue, during its progress. Diarrhoea, he thought, was in
such cases by no means to be considered an unmixed evil. In discussing the
treatment of the different forms of metria, he observed that, while all but useless
in the epidemic form, it was often of great service in the septicemic cases.

He formulated the following conclusions as founded on his experience : 1. A
disease of a highly infectious nature, differing essentially in its symptoms and
course from that the result of septic poisoning, and capable of being propagated
in the same manner as other zymotic diseases, occurs from time to time among
puerperal women. 2. This disease originated from the introduction into the
system of a puerperal woman of the infection of some well-known zymotic disease,
such as erysipelas, scarlatina, typhus, and probably typhoid fever, the action of
the infection being modified by the peculiar state of the system and of the blood
which exists in puerperal women, and that it, therefore, develops in them an
apparently totally different disease. 3. The disease thus originating can be
stamped out with as great ease, and by the same means as are known to be effi-
cacious in the case of ordinary zymotic diseases. He was satisfied, however, that
the majority of cases of so-called puerperal fever are the results of septic poison-
ing; such form of the disease not being capable of spreading through the air. —
Brit. Med. Journal, April 28, 1883.

Vaseline in Obstetrics.
The experiments of Koch, in 1881, showed not only that vaseline had no anti-
septic property, but that carbolic acid, when mixed with it or oil, lost the anti-
septic power which it had. But if the mixture is made in the presence of water or
of tissues containing water in abundance, about one-fourth of the carbolic acid is
freed from the mixture and partly recovers its antiseptic properties. When car-
bolized oil or vaseline is carried by the exploring-finger into the vagina, a burning
sensation is produced, much more intense with vaseline than with oil ; this seems
to prove that vaseline more readily gives up the carbolic acid than oil. In a
gynecological or obstetrical examination carbolized vaseline or oil coming in con-
tact, both with the finger of the examiner and with the tissues and secretory pro-
ducts of the vagina, exercises a certain degree of antisepsis, which, though slight,
is sufficient if the hand of the examiner has been previously well Avashed with an
antiseptic fluid. Carbolized vaseline then can only be replaced in obstetrical prac-
tice by some agent which may be preferable to it antiseptically, and at present
there are no well-grounded reasons for abandoning it. Fehling claims many ad-
vantages for paraffin containing 4 parts to 100 of carbolic acid. It is ordinarily
supposed that carbolic acid evaporates more readily from a solution than water,
but Schiicking has shown that this is an error. In any solution containing both
water and carbolic acid the water evaporates soonest. — Centralbl. fur Gynecolo-
gies March 10, 1883.

Vaccination during Pregnancy ; its Effect in the Foetus.
A recent number of the Zeitschrift fur Geburtsclmfe und Gyndkologie con-
tains a laborious article by Dr. Carl Behm, of Berlin, on the above subject.

292

Progress of the Medical Sciences.

[July

The question whether the blood-changes wrought by vaccinia germs affect the
foetus in utero as well as the mother has been a good deal discussed on merely
theoretical grounds. Bollinger formulated the doctrine that the placenta formed
a kind of physiological filter by which corpuscular matters in the maternal blood
were held back, and prevented from contaminating the foetus. But since then
Spitz and Albrecht have detected the spirillum of relapsing fever in the blood
of the new-born infant — an observation which appears to refute the dogma of
Bollinger. He has, consequently, since retracted this proposition ; and, believing
it possible for blood-poisons, whether corpuscular or not, to pass from the mother
to the foetus, he has stated that when a pregnant woman is successfully vaccinated
the foetus participates in the infection, and, it of course follows, in the protection
conferred thereby. The same view has been taught by Curschmann. These
conclusions are supported by certain published cases in which the vaccination of
children, whose mothers had been vaccinated during pregnancy, was effected
without result. Isolated cases, however, prove nothing, for the failures may have
been due, for instance, to bad lymph, or to unskilful performance of the opera-
tion. The most numerous observations are those of Burckhardt, who vaccinated
twenty-eight pregnant women ; but, of their children, in only eight was the
inoculation successful. This series, however, was not tested, as it should have
been, by the vaccination, with precisely the same kind of lymph and in the same
manner, of children whose mothers had not been vaecinated during pregnancy.
Opposed to these are observations of Gast, who vaecinated 1G mothers during
pregnancy, and subsequently every one of their children, with success. This
divergence in the results of experience led Dr. Behm to investigate the matter.
He vaccinated 47 pregnant women, but was only able to get at the children of
33. Of these 33 mothers, 22 were vaccinated in the tenth lunar month of preg-
nancy, 10 in the ninth, and 1 in the eighth. In 4 the vaccination was ineffectual, in
3 of them the non-success being proved to be due to the lymph employed. In the
remaining 29 pregnant women successfully vaccinated, in 7 the vesicles were not
good, but in 22 the inoculation produced perfect and typical vaccine vesicles.
Of the 33 children, 25 were vaccinated successfully. 8 unsuccessfully. Of the>e
failures, 6 were (by test vaccinations on other children) shown to be due to bad
lymph. In 1 of the other two the lymph used, although it produced vesicles in
other children, did not produce good ones. In the remaining case, the lymph
employed was good and potent. But this case, Dr. Behm remarks, ought to be
tested by repeated inoculations before concluding that the non-success was due
to protection acquired in utero from the vaccination of the mother.- The children
of the 4 mothers in whom vaccination had failed were vaccinated with perfect
success. Of the remaining 21. in 15 perfect vesicles were the result; in 6 the
vesicles were slightly modified, being few in number or small, but all ran a
typical course. Dr. Behm therefore concludes that vaccination of the mother
during pregnancy has little, if any, influence on the foetus; but it is possible that
it may sometimes protect the foetus. He concludes with an argument for the
revaccination of pregnant women, and the vaccination of infants as early as
possible. — Med. Times and Gazette, March 10, 1883.

A Case in xohich Cysts in connection with both Kidneys were opened and drained,
and a Tumour of the Right Ovary removed, the patient remaining in good
health.

Mr. Knowsley Thornton, at a meeting of the Medieo-Chirurgieal Society
(British Med. Journal, May 26, 1883), reported the following very curious and
interesting case : —

1883.]

Midwifery and Gynaecology.

293

E. M., a single woman, aged 27, was admitted into the Samaritan Hospital in
November, 187 7, under the care of Mr. Spencer Wells. She had had a child
born alive at full term when she was only fifteen. When seventeen, she had in-
flammation of both kidneys, and from that time had been failing in health and had
been unable to lie on her right side for fully a year. When admitted, she had a
fluctuant tumour of considerable size in the right side of the abdomen, with a red,
tender, and pointing swelling in the right loin behind this tumour. There was a
smaller tumour in the left side of the abdomen, which occupied an exactly similar
position to that in the right side, but did not distinctly fluctuate. There was
nothing wrong with the urine, and no trouble Avith the bladder or kidneys, except
pain across the loins and in the lower abdomen, which was not, however, con-
stant. Menstruation was regular. The swelling in the right loin was freely in-
cised by Mr. Wells under Listerian management, but nothing to account for its
presence was found, and no communication appeared to exist between it and the
kidney or ureter. It contained fluid very like that from an ovarian cyst, with
an immense quantity of cholesterine. It was dressed antiseptically and drained,
and in six weeks the patient went home well, all trace of the cyst having disap-
peared. Six or eight weeks afterwards, she had an attack of gout in both feet ;
then the wound opened, and a large discharge of fluid, with much cholesterine,
took place, and the wound gradually healed up again. In January, 1880, she
was readmitted under the author's care, with a tumour of the right ovary, for
which he performed ovariotomy. While the abdomen was open, he examined
the kidneys and ureters. The right kidney was large and sacculated, and its
ureter was much enlarged, especially at the pelvic brim. The left kidney and
ureter appeared quite normal. The recovery after the ovariotomy was rapid, but,
soon after getting up, the swelling in the right loin reappeared with fever, etc.,
and she was obliged to return to bed. It was poulticed antiseptically until it
broke, and then drained as before, and she left the hospital apparently well in
three weeks from the time it burst, and about six. weeks from the ovariotomy.
In six weeks she returned with a swelling in the left iliac region, in the situation
of the left ureter ; this was opened and drained antiseptically, and again in about
six weeks she went home well. Fifteen months later, the wound in the right
side again opened, and discharge went on for fourteen months without apparently
affecting her health at all. It had now again closed for two months, and she was
in excellent health. The left side had not given any further trouble.

The Propriety of Operating in Cases of Solid Ovarian Tumours.

Mr. Kxowsley Thornton in a brief but interesting article in the Medical
limes and Gazette for April 7, 1883, states that he has performed 338 ovarioto-
mies, and in 10, or nearly 3 per cent., he has encountered solid tumours of the
ovaries, a remarkably small proportion when we consider the structure of the
ovary, and the variations of blood supply and pressure to which its stroma is sub-
jected during the performance of its physiological functions Small as the num-
ber of these cases is, they plainly show as a group certain common features.

In all the cases menstruation was irregular. In three the menses were entirely
or almost entirely suppressed from the time the tumours were noticed, though in
one of these cases only one ovary was affected ; in four the menstruation was
regular, but affected in quantity ; and in another, though regular, the pain in the
tumour at this time was so excessive, that on the last occasion before the
operation, she almost died in collapse ; in the other two cases the menstruation
was very irregular — now scanty and almost suppressed, then violent and exhaust-
ing in amount. Of course, irregular menstruation is also met with in simple

294 Progress of the Medical Sciences. [July

ovarian cases, but the rule with them is regularity. With the malignant eases
the rule is, as we see, irregularity.

Mr. Thornton does not think that pain is more common or more severe with
the solid than with the simple cystic tumours ; nor is the emaciation more rapid
or more marked.

The differential diagnosis most frequently required in these cases is from ute-
rine fibroids, and the irregular menstruation helps to mislead, but the facies is
usually different, especially in colour; and whereas patients are usually inclined
to be robust with fibroids, and are often fat (even when excessively blanched),
extreme wasting, especially about the neck, breast, and arms, is the rule with
solid ovarian tumours.

Mr. Thornton thinks it will ever remain impossible to formulate any precise rule
as to the wisdom of operating or not operating in cases in which solid ovarian
tumour or tumours can be pretty certainly diagnosed. My experience, not only
in these particular cases, but in what I have seen in the practice of others, would
lead me to the opinion that the immediate danger to the patient is greater than
in ordinary ovariotomies, whether complicated or uncomplicated, and this is what
one would expect when he considers that the patient's general constitutional
condition is already depressed, and that frequently ligatures have to be applied
on and among unhealthy tissues, portions of such tissue also having sometimes to
be left behind more or less damaged, and with its nutrition impaired. My own
ten cases illustrate this increased immediate mortality distinctly, for three out of
the ten died from the operation — a mortality triple that of my whole series of
cases, six times as great as that of my recent work, and thirty times as great as
that of my simple cases, in which my mortality is nil.

If we now pass from the consideration of the immediate danger to the question
of the chances of early recurrence, my experiences are not very encouraging.
Of the seven cases which survived the operation, three were very ill and recov-
ered with difficulty, four recovered rapidly and easily. Of the three, only one
remains in good health, and had a child two years after the operation ; one (ease
4), who was reported in good health eighteen months after the operation, is now
suffering from recurrence in the abdomen ; the third died, as I have stated, a few
months after the operation, from pelvic recurrence. Of the four who made good
recoveries, one died within the year from peritoneal recurrence, and the other three
all died within the twelve months with diffuse sarcomata in various external and
internal situations and in the glands. This rapid and general diffusion of sarco-
mata of the ovary after operations for their removal seems to me to make it ex-
tremely doubtful whether it is not a positive injustice and cruelty to the patient
to operate at all, for their sufferings from the many tumours are undoubtedly
greater than they would be from the ovarian growths left alone. There lives are, it
is true, prolonged for a few months, but the period of actual health is very short.
Still, in case 4, which appeared as hopeless as any case well could, the patient
has enjoyed eighteen months of good health, much better than any she had en-
joyed for years ; and in the one really satisfactory case the patient not only remains
well, but has become again a mother. No case could have looked more hopeless
than this one did, and the tumour was of a kind in which one would have feared
early recurrence. In considering the cases of patients doomed to speedy death
if not operated upon, one such result as this out often comparative failures is not
to be despised, and so I think I shall be inclined still to give the patient the
.chance of operation, unless there is such distinct evidence of spread of the disease
into broad ligament or neighbouring parts that complete removal is out of the
question.

1883.] Medical Jurisprudence and Toxicology. 295

Fibroma of the Round Ligament.

Prof. Ludwig Kleinwachter describes, in a recent number of the Zeits-
chrift fur Geburtshiilfe unci Gynakologie, a case of fibroma of the round liga-
ment, which is interesting on account of the extreme rarity of that condition.
The only case which Professor Kleinwachter has been able to find is described by
Winckel, and in it neither of the tumours, of which there was one on each round
ligament, exceeded a bean in size. Dr. Kleinwachter' s case was that of a mul-
tipara aged forty-four. The tumour reached to two fingers' breadths above the
umbilicus, it caused slight pain, and was said to increase in size before and during
each menstruation. The tumour was situated more to the right than to the left
of the middle line, and when it was pushed upward pain was complained of in
the region of the right Poupart's ligament. The uterus was pushed to the right
of and behind the tumour, which filled the pelvic brim. The tumour was re-
moved, the operation being long and difficult, owing to the number of adhesions
present. The clamp was applied to the pedicle, and two drainage-tubes inserted.
The patient died from peritonitis on the third day. On autopsy, both ovaries
and tubes were found healthy, and the pedicle of the tumour was situated on the
left round ligament, about an inch from its origin. The uterus was enlarged, but
the nature of the enlargement is not stated. The tumour was solid, fibrous in
structure, and weighed about three pounds and a half. Looking at the rarity of
this disease of the round ligament, the numerous adhesions present, and the
uterine enlargement, it might be suggested, and it is to be regretted that Pro-
fessor Kleinwachter does not discuss the point, that the tumour was originally a
uterine fibroid which had become united by adhesions to the round ligament, and
subsequently severed from its old attachment. — Med. Times and Gaz., April 28,
1883. __

The Sharp Spoon in Gyncecology.

A recent number of the Archiv fur Gynakologie contains an excellent article by
Dr. v. Weckbecker-Sternefeld, of Munich, on the use of the sharp spoon in
gynaecology. This writer's statements are based upon experience, for he gives a
table and careful analysis of one hundred cases in which he has used the instrument
which he recommends. In this absence of haste it would be well if his example
were more generally followed ; for we have known instruments exhibited,
and lines of practice laid down, by men who had never once used their instru-
ments, or seen a case calling for the practice they write about. The cases in
which Dr. v. Weckbecker-Sternefeld advises the use of the sharp spoon (which,
we may mention, is that known as Simon's) are these: In abortion, when the
ovum or membranes, or part of them, are from any cause retained in utero ; in
cases of mole, vesicular or fleshy ; after labour, in cases of hemorrhage or fetid
discharges, caused by retention of bits of placenta or membranes, or polypoid
growths at the placental site. The advantages of the sharp spoon (as compared
with the digital detachment and removal of such offending bodies), he thinks, are
these : avoidance of septic infection ; the small space required for its use ; the
completeness with which detached bodies can be removed in the hollow of the
spoon ; the almost painlessness of the proceeding for the patient ; the absence of
dragging upon the uterus ; and the unirritating character of the proceeding. The
instrument is used, of course, in the same way as the curette ; it may, in fact, be
regarded as a large curette, so shaped as to be capable not merely of detaching,
but of bringing away any mass loosely attached to the uterine wall. The size of
spoon which Dr. v. Weckbecker-Sternefeld finds most generally useful is about
an inch long by rather more than half an inch across. The angle at which the

296

Progress of the Medical Sciences.

[July.

spoon is set on the handle matters little, but it is convenient to have the direction
of the convexity and concavity of the spoon indicated by marks on the handle.
Its use does not give pain enough to make anaesthesia necessary. Our author, as
we have mentioned, gives a careful analysis of one hundred cases in which lie has
used the sharp spoon. Of these, in nine it was employed for the removal of an
ovum in process of expulsion ; in thirty-one for removal of membranes, or por-
tions of them, after the embryo had been discharged ; in twenty-seven, for re-
moval of placenta, or portions of it, after premature delivery ; in twenty-eight,
for the same purpose after delivery at term ; in two, for atony of the uterus post-
partum ; and in the others, for endometritis, deciduoma at the placental sile,
placental polypus, fleshy and hydatid mole. Of the one hundred cases five died ;
three from puerperal septicaemia existing before the operation was undertaken,
one from enteric fever, one from peritonitis. The last mentioned our author
considers the only one in which the fatal result could be connected with the opera-
tion, but in this there was also some disease of the rectum, and a previous attempt
had been made to effect manually the object for which the spoon was used. In
most cases no bad symptoms followed, and the patients quickly recovered. —
Medical Times and Gazette, May 19, 1883.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

Intra- Peritoneal Injections in Cases of Poisoning.

Dr. Wm. Murrell says, in regard to Dr. Ringer's suggestion of the injection
of saline solutions in cases of poisoning, it is generally supposed that the intro-
duction of fluids into the peritoneal cavity is an operation attended with con-
siderable risk, but the experimental observations of Ponfick and of Bizzozero
and Golgi have shown that defibrinated blood can be injected into the abdomen
with little or no danger. Ponfick relates that in 'one case 250 grammes of blood
were transfused, in another 350, and in a third 220 grammes. The results were
most satisfactory, the only unfavourable symptoms being a little tenderness of
the abdomen and a slight and transitory elevation of temperature.

Recently, I have had occasion to resort to intra-peritoneal injection six times,
•and in four instances I have used Ringer's solution with much benefit. The
only apparatus employed was the canula of the aspirator, attached to a piece of
India-rubber tubing, the fluid, warm to the temperature of the body, being
allowed to run in by siphon action. The canula was pushed through the abdo-'
minal wall on one side, no special antiseptic precautions being taken. The
first injection measured 500cc, or about fifteen ounces, the second half that
quantity, and the third 600cc. In a case of peritonitis in a child, serous fluid to
the amount of 320cc. was drawn off by the aspirator, and the peritoneum was
then washed out with 400cc. of the salt solution. The temperature on the fol-
lowing day rose to 102°, but with this exception there were no unfavourable
symptoms.

In cases of emergency it may not be practicable to prepare Ringer's solution
in exact accordance with his directions; but the following formula, which is
almost identical- with that recommended by him, can be quickly dispensed:
Common salt, one drachm ; bicarbonate of soda, four grains ; chloride of calcium,
three grains ; chloride of potassium, one grain ; water, twenty ounces, at a tem-
perature of 100° Fahr. This may be used either for intra- venous or intra-peri-
toneal injection. — Lancet, April 21, 1883.

American Journal of the Medical Sciences.

297

THE

JEFFERSON MEDICAL COLLEGE

OF PHILADELPHIA.

TnE Fifty-ninth Session of the Jefferson Medical College will begin on Monday,
October 1st, 1883, and will continue until the end of March, 18S4. Preliminary Lectures
will be held from Monday, 11th of September.

PROFESSORS.

S. D. GROSS, M.D. , LL.D., D.C.L. Oxon., ROBERTS BARTIIOLOW, M.D , LL.D. ,
LL.D. Cantab. (Emeritus). Materia Medica and General Therapeutics.

HENRY C. CHAPMAN, M.D.,
Institutes of Medicine and Medical
Jurisprudence.

SAMUEL W. GROSS, M.D ,
Principles of Surgery and Clinical Surgery.

JOnN H. BRTNTON, M.D.,
Practice of Surgery and Clinical Surgery.

Institutes and Practice of Surgery.
ELLERSLTE WALLACE, M.D. ,
Obstetrics and Diseases of Women and
Children.

J. M. DA COSTA, M.D.,
Practice of Medicine.

WM. H. PANCOAST, M.D.,
General, Descriptive, and Surgical Anatomy

ROBERT E. ROGERS, M.D., WILLIAM THOMSON, M.D

Medical Chemistry and Toxicology. Professor of Ophthalmology.

To the usual course of instruction in medical schools, the Medical Faculty of this
College have added a thorough system of practical Laboratory work. To each course
of the regular curriculum there is appended a Laboratory Course, carried on in large
and thoroughly equipped apartments in the College, by specially appointed Demonstra-
tors, under the immediate direction of the Professor. In this way each candidate for the
degree of M D. is immediately and personally taught in Obstetrics and Gynaecology,
Physical Diagnosis, Laryngology, Ophthalmology, Medical Chemistry, Pharmacy, Materia
Medica and Experimental Therapeutics, Physiology, Histology and Experimental
Physiology, and Minor Surgery, Bandaging, Operations on the Cadaver, etc. In the
Department of Medicine, "clinical conferences," and practical lessons in Physical
Diagnosis, give each student familiarity with p!1 forms of disease. The experience of
several Sessions has abundantly demonstrated the great value of this Practical Teaching.

This course of Instruction is free of charge, but obligatory upon candidates for the
Degree, except those who have had such instruction and those who are Graduates of
other Colleges of ten years' standing.

A Spring Course of Lectures is given, beginning early in April, and ending early in
June. There is no additional charge for this Course to matriculates of the College, ex-
cept a registration fee of five dollars; non-matriculates pay forty dollars, thirty- five of
which, however, are credited on the amount of fees paid for the ensuing Winter Coarse.

A Post Graduate Course, very complete in all the details of instruction, has been
organized for practitioners only.

CLINICAL INSTRUCTION is given daily at the HOSPITAL OF THE JEFFERSON
MEDICAL COLLEGE throughout the year by Members of the Faculty, and by the Hos-
pital Staff.

FEES.

Matriculation Fee (paid once) $5 00 I Practical Anatomy $10 00

Ticket for each Branch (7) $20 140 00 1 Graduation Fee 30 00

Fees for a full course of Lectures to those who have attended two full courses at

other (recognized) Colleges — the matriculation fee, and ?70 00

To Graduates of less than ten years of such Colleges — the matriculation fee, and $50 00
To Graduates of ten years, and upwards, of such Colleges — the matriculation fee only.
To Dental Graduates the first course is $60, and the second is $100.
To Graduates in Pharmacy the general ticket is $100 for each year.

The Annual Announcement, giving full particulars, will be sent on application to

ROBERTS B ARTHOLO W M.D., Deem.

298

American Journal of the Medical Sciences.

UNIVERSITY OF PENNSYLVANIA — MEDICAL
DEPARTMENT.

Thirty-Sixth Street and Woodland Avenue {Darby Road), Philadelphia.
One Hundred and Eighteenth Annual Session, 1883-84.

PROFESSORS,

WILLIAM PEPPER, M.D., LL.D., Provost. (HORATIO C. WOOD, M.D., Materia Medica,

Pharmacy, and General Therapeutics.

JOSEPH LEIDY, M.D., LL.D., Anatomy. THEODORE G. WOEMLET, MI)., LL.D.,

RICHARD A. F. PENROSE, M.D., LL.D., Ob- ! Chemistry.

stetrics and Diseases of Women and Chil- j JOHX ASII1IURST, Jr., M.D., Clinical Surgery.

dren.

ALFRED STILLE, M.D., LL.D., Theory and ! HARRISON ALLEX, M.D., Pysiology.

WILLIAM F. NOERIS, M.D., Clinical Professor
of Diseases of the Eye.

GEORGE STRAWBRIDGE, M.D., Clinical Pro-

Practice of Medicine, and Clinical Medic
D. HATES AGNEW, M.D., LL.D , Surgery and of Diseases of the Ey
Clinical Surgery.

WILLIAM PEPPER, M.D., LL.D. , Clinical | ~"Yes*orl[ DisezeesVt The Ear"
Medicine.

WILLIAM GOODELL, M.D., Clinical Gynajco- HORATIO C. WOOD, M.D., Clinical Professor
locry 1 ot Nervous Diseases.

JAMES TYSON, M.D., General Pathology and LOUIS A. DUHRING, M.D., Clinical Professor
Morbid Anatomy. J <'l Diseases of the Skin.

Students who have not received a collegiate degree or who do not furnish the evidence of
sufficient previous education referred to in the Catalogue, are required to pass an admission
examination in English, and Physics, for details of which see Catalogue.

Attendance is required upon three winter courses of graded instruction, six and a half months
in duration, and consisting of didactic lectures, clinical lectures, and practical work in labora-
tories and hospitals.

A voluntary FOURTH year, almost purely practical, has been established, i n addition to which
there is a distinct and separate course for graduates, for particulars of which see Catalogue

The Lecnirp.fi of the Winter Session of 1SS3-S4 will begin on Monday, October 1st, and end on
the IMh day of April.

The Preliminary Course will begin on the second Monday in September.

In the Spring Months the laboratories of Chemistry, Pharmacy, Histology, Physiology, and
Pathology are open, and the post-graduate clinical instruction is continued

Fees in Advancr.— Matriculation $3. For each Session, including dissections, operating, and
bandaging, $100. No graduation fee.

For Catalogue giving full particulars, address

JAMES TYSON, M.D., Secretary,

P. O. Box 283S, Philadelphia, Pa

THE MEDIOAL DEPARTMENT

TALE COLLEG-E

Has adopted a graduated course of study extending through
three years. Each year is divided into three terms.

The First Term will begin on Thursday, October 4th, 1883,
and close on Wednesda}% December 20th. The Second Term
will begin on Thursday, January 10th, 1884, and close April 3d.
The Third Term will begin Thursday, April 10th, and close with
Commencement, June 28th.

FEES AND EXPENSES.

Matriculation Fee $5 00

Tuition Fee for 1st and 2d year, each . . 125 00
Tuition Fee for 3d year ' . . . . 75 00

Graduation Fee 30 00

For further information address

C. A. LIKDSLEY, M.D., Dean,

New Haven, Conn.

American Journal of the Medical Sciences.

299

HARVARD UNIVERSITY.

MEDICAL DEPARTMENT, BOSTON, MASS.
ONE HUNDRED AND FIRST ANNUAL ANNOUNCEMENT (1883-84).

FACULTY.
Charles W. Eliot, LL.D., President.

Calvin Ellis, M.D., Dean, and Jackson Professor of Clinical Medicine.
Oliver W. Holmes, M.D., LL.D., Parkman Professor of Anatomy, Emeritus.
Henry J. Bigelow, M.D., Professor of Surgery, Emeritus.
Francis Minot, M.D., Hersey Professor of the Theory and Practice of Physic.
John P. Reynolds, M.D., Professor of Obstetrics.
Henry W. Williams, M.D., Professor of Ophthalmology.
David W. Cheever, M.D., Professor of Surgery.
James C. White, M.D., Professor of Dermatology.
Robert T. Edes, M.D., Professor of Materia Medica.
Henry P. Bowditch, M.D., Professor of Physiology.
Charles F. Folsom, M.D., Assistant Professor of Mental Diseases.
Frederick I. Knight. M.D., Assistant Professor of Laryngology.
Charles B. Porter, M.D., Assistant Professor in Surgery.
J. Collins Warren, M.D., Assistant Professor in Surgery.
Reginald H. Fitz, M.D., Shattuck Professor of Pathological Anatomy.
William L. Richardson, M.D., Assistant Professor of Obstetrics.
Thomas Dwight, M.D , Instructor in Topographical Anatomy and Histology.
•Edward S. Wood, M.D., Professor of Chemistry.
William H. Baker, M.D., Assistant Professor of Gynaecology.
William B. Hills, M.D , Instructor in Chemistry.
William F. Whitney, M.D., Curator of the Anatomical Museum.

OTHER INSTRUCTORS.
Frank W. Draper, M.D., Lecturer on Forensic Medicine.
Henry P. Quincy, M.D., Assistant in Histology.

Edward N. Whittier. M.D., Instructor in the Theory and Practice of Physic.

Francis A. Harris, M.D., Demonstrator of Medico-legal Examinations.

William P. Bolles, M.D , Instructor in Materia Medica.

Edward H. Bradford. M.D., Assistant in Clinical Surgery.

W Sturgis Bigelow, M.D., Assistant in Surgery.

Francis H. Davenport, M.D., Assistant in Gynaecology.

George M. Garland, M.D., Assistant in Clinical Medicine.

Joseph W. Warren, M.D., Assistant in Physiology.

Maurice H. Richardson, M.D., Demonstrator of Anatomy

William W. Gannett, M.D., Assistant in Pathological Anatomy.

Charles S. Minot, M.D., Lecturer on Embryology.

Wtilliam C. Emerson, M.D.. Assistant in Chemistry.

Walter J. Otis, M.D., Assistant in Anatomy.

Samuel J. Mixter, M.D., Assistant in Anatomy.

The following gentlemen will give special clinical instruction: —
John Homans, M.D., in the Diagnosis and Treatment of Ovarian Tumors.
Francis B. Greenough, M.D., and Abner Post, M.D., in Syphilis.
Oliver F. Wadsworth, M.D., in Ophthalmoscopy.
J. Orne Green, M.D., and Clarence J. Blake, M.D., in Otology.
Amos L. Mason, M.D., and Fred C. Shattuck, M D., in Auscultation.
Joseph P Oliver, M.D., and Thomas M. Rotch, M.D , in Diseases of Children.
Samuel G. Webber, M.D., and James J. Putnam, M.D., in Diseases of the Nervous

System.

James R. Chadwick, M.D., in Gynaecology.

The New Building, just completed at a cost of more than a quarter of a million of dollars, will
be opened for use in September. Its numerous apartments are spacious, well lighted, and provided
with carefully contrived apparatus for heating and ventilation. The comfort and convenience of
the students have been constantly borne in mind in the arrangement of rooms, the construction of

300

American Journal of the Medical Sciences.

seats, and in the furnishing of the various laboratories, balls for lectures, and room* for recitations,
study, and conversation. The buildiu? is devoted to laboratory insiruc ion and didactic teaching,
while the general aud special clinics take place at the various hospitals and dispensaries Greatly
enlarged and improved facilities will be offered at the Massachusetts General Hospital and the
Bostou Dispensary, both of which institutions are now constructing buildings to mtet the con-
stantly increasing demands for their usefulness.

All candidates for admission who hold no degree in arts or science, must pass a written exami-
nation on entrance to this School, in Eugtish, Latin, Physics, and anyone of the following sub-
jects: French, German, Elements of Algebra or of Plane Geometry, Botany. The admission
examination for 18S3-S4 will be held June 2o, at Bostou; June 28 h, at Exeter, New i'ork, Phila-
delphia, Chicago, Cincinnati, and San Francisco; on September 24th, at Boston only.

Instruction is given by lectures, recitations, clinical teaching, and practical exercises, distributed
throughout the academic year. In the subjects of anatomy, histology, chemistry, and pathological
anatomy, laboratory work is largely substituted for, or added to, the usual methods of instruction.
The year begins September 27, 1SS3, aud ends on the last Wednesday in Juue, 1SS1, and is divided
into two equal terms.

Studeuts are divided into four classes, according to their time of study and proficiency, and duri ug
their last year will receive largely iucreased opportunities for instruction io the special branches
mentioned Students who begau their professional studies elsewhere may be admitted to advaucd
staudtng ; but all persous who apply for admission to the advanced classes must pass an exami-
nation in the branches already pursued by the class to which they seek admission.

Although the course of study recommended by the Faculty covers four years, uutil further notice
the degree of Doctor of Medicine will continue to be given upon the completion of three years of study,
to be as ample and full as heretofore. The degree of Doctor of Medicine cum land", wilt be given
to candidates who have pursued a complete four years' course, aud obtained an average of 75 per
cent, upon all the examiuatious of this course. lu addiiion to the ordinary degree of Doctor of
Medicine as heretofore obtained, a certificate of attendance on the studies of the fourth year will
be given to such students desiring it as shall have attended the course, aud have passed a satis-
factory examination in the studies of the same.

ORDER OF STUDIES. — Four Ykars' Course.
For the. First Year. — Anatomy, Physiology, and General Chemistry.

For the Second Year. — Practical and Topographical Anatomy, Medical Chemistry, Materia Medi-
ca, Pathological Anatomy, Clinical Mediciue, Surgery, and Clinical Surgery.

For the Third Year —Therapeutics, Obstetrics, Theory aud Practice of Mediciue, Clinical Medi-
cine, Surgery, and Clinical Surgery.

Fir the Fourth Year. — Ophthalmology, Otology. Dermatology, Syphilis, Laryngology, Mental
Diseases, Diseases of the Nervous System, Diseases of Women, Diseases of Children. Obstetrics,
Clinical and Operative Obstetrics, Clinical Medicine, Clinical aud Operative Surgery, Forensic
Medicine.

Three Yeabs' Course.
For the First Year. — Anatomy, Physiology, and General Chemistry.

For the Second, Year — Practical and Topographical Anatomy, Medical Chemistry, Materia
M^dica, Pathological Anatomy. Clinical Medicine, and Cliuical Sureery.

For the Third Year — Therapeutics, Obstetrics, Theory and Practice of Medicine, Cliuical Medi-
cine, Surgery, Clinical Surgery, Ophthalmology, Dermatology, Syphilis, Otology, Laryngology,
Mental Diseases, Diseases of the Nervous System, Diseases of Women, Diseases of Children,
Forensic Medicine.

ANNUAL EXAMINATIONS

At the end of the first year — Anatomy, Physiology, and General Chemistry.

End of second year — Topographical Anatomy, Medical Chemistry, Materia Medica, and Patho-
logical Anatomy.

End of third year — Therapeutics, Obstetrics, Theory and Practice of Medicine, Surgery. (Stu-
dents of the three years' course are also examined iu Clinical Medicine and Clinical Surgery. )
End of fourth year — Ophthalmology. Otology, Dermatology, Syphilis, Laryngology, Mental
Diseases, Diseases of the Nervous System, Diseases of Women, Diseases of Children,
Obstetrics, Clinical and Operative Obstetrics, Cliuical Medicine, Clinical and Operative Sur-
gery, Forensic Medicine.
Examinations in all subjects are also held before the opening of the School, beginning Septem-
ber 26th.

Requirements for a Degree.— Every candidate must be twenty-one years of age ; must have
studied medicine three or four full years, have spent at least one continuous year at this school,
have passed a written examination upon all the prescribed studies of the course taken, and have
presented a thesis.

Codrse for Graduates. — For the purpose of affording to those already Graduates of Medicine
additional facilities for pursuing clinical, laboratory, and other studies, the Faculty has established
a course which comprises all of the special subjects of the fourth year in addition to private
instruction iu Histology, Physiology, Medical Chemistry, a d Pathological Anatomy. Any or all
branches may be pursued. If the full fee is paid, the privilege of attending any of the other exer-
cises of the Medical School, the use of the laboratories and library, and all other rights accorded
by the University will be granted. Graduates of other Medical Schools who may desire to obtain
the degree of M.D. at this University, will be admitted to examination for this degree after a year's
study in the Graduates' Course. Examination on entrance not required.

Fess. — For Matriculation. $.5 ; for the Year, *200 ; for one Term alone, §120 ; for Graduation. $;i0.
For Graduates' Course, the fee for one year is $200 : for one Term, $120 : aud for siugle courses such
fees as are specified in the Catalogue. Payment in advance, or if a bond is filed, at the end of the
term.

Students in regular standing in any one department of Harvard University are admitted free to
the lectures, recitations, and examinations of other departments.

For further information, or Catalogue, with an illustrated description of the New Building,
address

Dr. R. H. FITZ, Secretary,

18 Arlington St., Boston, Mass.

American Journal of the Medical Sciences

301

UNIVERSITY OF THE CITY OP NEW YORK,

MEDICAL DEPARTMENT.

410 East Twenty -sixth St., opp. Bellevue Hospital, New Yorte City.

FORTY-THIRD SESSION, 1883-84=.

FACULTY OF MEDICINE.

Rev. JOHN HALL, D.D., LL.D., Chancellor of the University, pro tern.

ALFRED C. POST, M.D., LL.D., Professor
Emeritus of Clinical Surgery ; President of
the Faculty.

CHARLES INSLEE PAK DEE, M.D., Dean of
the Faculty; Professor of Otology; Surgeon
to the Manhattan Eye and Ear Hospital.

J. W. S. ARNOLD, M.D., Emeritus Professor of
Physiology and Histology.

JOHN C DRAPER, M.D., LL.D., Professor of
Chemistry.

ALFRED L. LOOMIS, M.D., Professor of Patho-
logy and Practice of Medicine ; Visiting Phy-
sician to Bellevue Hospital

WM. DARLING, M.D., LL.D., F.R.C.S., Pro-
fessor of General and Descriptive Anatomy.

WILLIAM H. THOMSON, M.D., Professor of
Materia Medica, Therapeutics and Diseases of
the Nervous System ; Visiting Physician to
Bellevue Hospital.

. WILLISTON WRIGHT, M.D., Professor of

Surgery; Visiting Surgeon to Bellevue Hos- I JOSEPH E. WINTERS, M.D., Demo
pital. 1 Anatomy.

WM. M. Polk, M.D., Professor of Obstetrics
and the Diseases of Women aud Children ;
Gynaecologist to Bellevue Hospital.

LEWIS A. STIMSON, M.D., Professor of Physio-
logy and Physiological Anatomy; Surgeon to
Bellevue Hospital ; Curator to Bellevue Hos-
pital.

| FAN EUIL D. WEISSE, M.D., Professor of Prac-
tical and Surgical Anatomy ; Surgeon to Work-
house Hospital, B. I.

! STEPHEN SMITH, M.D., Professor of Cliuical
Surgery ; Surgeon to Bellevue Hospital.
A. E. MAC DONALD, LL.B., M.D., Professor of
Medical Jurisprudence aud Diseases of the
Miud ; Medical Superintendent of the New-
York City Asylum for the Insane.
R. A. WITTHAUS, M.D., Professor of Physio-
logical Chemistry.
HERMAN KNAPP, M.D., Professor of Ophthal-
mology ; Surgeon to the Ophthalmic Institute.
| AMBROSE L. R ANNE Y, M.D., Curator of Mu-
seum.

nstrator of

itomy.

ADJUNCT

D., Clinical Lecturei

Visiting Physician to

F. R. S. DRAKE, M

Practice of Medicin

Bellevue Hospital
N. M. SHAFFER, M.D., Clinical Lecturer on

Orthopedic Surgery ; Surgeon in Charge of

the N. Y. Orthopsedic Hospital.
P. A MORROW, M.D. Clinical Lecturer on

Dermatology.

LECTURERS.

JOSEPH E. WINTON, M.D.

Clinical Lecturer

on Diseases of Children.

WILLIAM C. JARVIS,
on Laryngology.

M.D., Clinical Lecturer

LAWRENCE JOH]
Medical Botany.

ISON, M.D., Lecturer on

THE PRELIMINARY SESSION will begin on Wednesday, September 19, 1883, and end October
3, 1SS3. It will be conducted on the same plan as the Regular Winter Session.

THE REGULAR WINTER SESSION will begin October 3, 1883, and end about the middle of
March, 1 SSI. The Plan of Instruction consists of Didactic and Clinical Lectures, recitation-s and
laboratory work in all subjects in which it is practicable. To put the laboratories on a proper
footing a new building has been erected at an expense of thirty-five thousand dollars. It will
contain laboratories fitted for instruction in Chemistry, Histology, Pathology, Materia Medica,
Operative Surgery and Gynaecology.

Two to five Didactic lectures and two or more Clinical lectures will be given each day by members
of the Faculty. In addition to the ordinary clinics, special clinical instruction , without additional
expense will be given to the candidates for graduation during the whole Regular Sessiou. For
this purpose the candidates will be divided into sections of twenty-five members each. At these
special clinics students will have excellent opportunities to make and verify diagnoses, and watch
the effects of treatment. They will be held in the Wards of the Hospitals aud at the Public and
College Dispensaries.

Each of the seven professors of the Regular Faculty will conduct a recitation on his subject one
evening each week. Students are thus enabled to make up for lost lectures, and prepare them-
selves properly for their final examinations without additional expense.

THE SPRING SESSION will begin about the middle of March and end the last week in May.
The daily Clinics and Special Practical Courses will be the same as in the Winter Session, and
there will be Lectures on Special Subjects by the Members of the Faculty. It is supplementary
to the Regular Winter Session. Nine months of continued instruction are thus secured to all
students of the University who desire a thorough course.

FEES.

For course of Lectures $140 00

Matriculation 5 00

Demonstrator's Fee, including material for dissection 10 00

Final Examination Fee 30 00

For further particulars and circulars address the Dean,

Prof. CHAS. INSLEE PARDEE, M.D.,
University Medical College, 410 East 26th St., New York City.

302

American Journal of the Medical Sciences.

MEDICAL DEPARTMENT OF THE UNIVERSITY OF
LOUISIANA—NEW ORLEANS.
FACULTY.

T. G. RICHARDSON, M.D., ERNEST S. LEWIS. M.D.,

Professor of General and Clinical Surgery. ; f rofessor of General and Clinical Obstetric?
SAMUEL M. BEMISS, M D., and Diseases of Women and Children.

Professor of the Theory and Practice of JOHN B ELLIOTT M D

Medicine and Clinical Medicine. Professor of Materia Medica and

STANFORD E. CHAILLE, M.D., Therapeutics and Hygiene.

Prof, of Physiology and Patholog. Anatomy. |

P f fpf^^Pr'^M LectuTeT^Diseases'oTtleEye.
Prof, of Chemistry and Clinical Medicine. , J

SAMUEL LOGAN, M.D., ALBERT B. MILES, M.D.,

Professor of Anatomy and Clinical Surgery. Demonstrator of Anatomy.

The next\annual course of instruction in this Department (now in the fiftieth year of its
existence) will commence on Monday, the 22d day of October, 1883, and terminate on
Saturday the 29th day of March, 1884. The first four weeks of the term will be devoted
exclusively to Clinical Medicine and Surgery at the Charity Hospital : Practical Chemis-
try in the Laboratory ; and dissections in the spacious and airy Anatomical Rooms of the
University.

The means of teaching now at the command of the Faculty are unsurpassed in the
United States. Special attention is called to the opportunities presented for

CLINICAL INSTRUCTION.

The Act establishing the University of Louisiana gives the professors of the Medical
Department the use of the great Charity Hospital, as a school of practical instruction.

The Charity Hospital contains nearly 700 beds, and received, during the last year,
nearly six thousand patients. Its advantages for practical study are unsurpassed by any
similar institution in this country. The Medical, Surgical, and Obstetrical Wards are
visited by the respective Professors in charge daily, from eight to ten o'clock A. M., at
which time all the Students are expected to attend, and familiarize themselves, at the
bedside op the patients, with the diagnosis and treatment of all forms of injury and
disease.

The regular lectures at the hospital, on Clinical Medicine by Professors Bemiss and
Joseph Jones. Surgery by Professors Richardson and Logan, Diseases of Women and
Children by Professor Lewis, and Special Pathological Anatomy by Professor Chaille,
will be delivered in the amphitheatre on Monday, Wednesday, Thursday and Saturday,
from 10 to 12 o'clock, A. M.

The Administrators of the Hospital elect, annually, after competitive examination,
fourteen resident Stddents, who are maintained by the Institution.

TERMS.

For the Tickets of all the Professors .... $140 00

For the Ticket of Practical Anatomy . . . 10 00

Matriculation Fee . . . . . . 5 00

Graduation Fees . . . . . . 30 00

Candidates for graduates are required to be twenty-one years of age ; to have studied
three years : to have attended two courses of lectures, and to pass a satisfactory examina-
tion.*

Graduates of other respectable schools are admitted upon payment of the Matriculation
and half lecture fees. They cannot, however, obtain the Diploma of the University with-
out passing the regular examination and paying the usual Graduation Fee.

As the practical advantages here afforded for a thorough acquaintance with all the
branches of medicine and surgery are quite equal to those possessed by the schools of
New York and Philadelphia, the same fees are charged.
For further information, address

T. G. RICHARDSON, M.D., Dean.
* For further information upon these points see circular.

American Journal of the Medical Sciences.

303

BELLE VUE HOSPITAL MEDICAL COLLEGE,

CITY OF NEW YORK.

SESSIONS OF 1883-84.

The standard of Medical E;hics recognized by the College is embodied in the Code
of Ethics of the American Medical Association.

The Collegiate Tear embraces the Regular Winter Session and a Spring Session.
The Regular Session begins on Wednesday, September 19, 1883, and ends about the
middle of March, 1881. During this Session, in addition to the regular didactic lectures,
two or three hours are daily allotted to clinical instruction. Attendance upon two
regular courses of lectures is required for graduation. The Spring Session consists
chiefly of recitations from Text-Books. This Session begins about the middle of March,
and continues until the middle of June. During this Session, daily recitations in all
the departments are held by a corps of Examiners appointed by the Faculty. Short
courses of lectures are given on special subjects, and regular clinics are held in the
Hospital and in the College building.

FACULTY.

ISAAC E. TAYLOR, M.D.,
Emeritus Prof, of Obstetrics and Diseases ot Women and Children, and President of the Faculty.

FORDYCE BARKER, M.D., LL.D.,
Professor of Clinical Midwifery aud Diseases
of "Women.
AUSTIN FLINT, M.D. .LL.D..
Prof, of the Principles and Practice of Medicine

and Clinical Medicine.
FREDERICK S. DENNIS, M.D.,
Professor of Principles and Practice of -Surgery
and Cliuical Surgery.

LEWIS A. SAYRE. M.D.,
Professor of Orthopedic Surgery aud Clinical
Surgery.
ALEXANDER B. MOTT, M.D.,
Professor of Cliuical aud Operative Surgery.
WILLIAM T. LUSK, M.D.,
Professor of Obstetrics and Diseases of Womeu
and Children, aud Cliuical Midwifery.

PROFESSORS OP SPECIAL. DEPARTMENTS

BENJAMIN W. McCREADY. M.D.,
Emeritus Professor of Materia Medica and
Therapeutics.
A A. SMITH, M.D.,
Professor of Materia Medica and Therapeutics,
and Clinical Medicine.
AUSTIN ELUNT, Jr., M.D.,
Professor of Physiology and Physiological
Anatomy, and Secretary of the Faculty.
JOSEPH D. BRY'ANT, M.D.,
Professor of Anatomy and Cliuical Surgery, and
Associate Professor of Orthopedic Surgery.
R. OGDEN DORE.MUS, M.D , LL.D.,
Professor of Chemistry and Toxicology.
EDWARD G. JANEWAY, M.D.,
Prof, of Diseases of the .Nervous System, and
Cliuical Medicine, and Associate Professor
of Principles and Practice of Medicine.

Etc.

HEXRY D. NOYES, M.D.,
Professor of Ophthalmology aud Otology.

EDWARD L. KEYES, M.D.,
Prof, of Cutaneous and Genito-l'riuary Diseases.

JOHN P. GRAY, M.D., LL.D..
Professor of Psychological Medicine aud Medical
Juri?prudence.

WILLTAM H. WELCH, M.D.,
Professor of Pathological Anatomy and
General Pathology.

J. LEWIS SMITH, M.D.,
Clinical Professor of Diseases of Children.
BEVERLY" ROBINSON, M.D.,
Cliuical Professor of Medicine.
FRAXCKE H. BOSWORTH, M.D.,
Professor of Diseases of the Throat.
CHARLES A. DORE.MUS, M.D. , Ph.D.,
Professor Adjunct to the Chair of Chemistry aud
Toxicology,
WILLIAM H. WELCH, M.D. ,
Demonstrator of Anatomy.

FEES FOR THE REGULAR SESSION.

Fees for Tickets to all the Lectures, Clinical and Didactic

Fees for Students who have attended two full courses at other Medical College

for Graduates of other Medical Colleges £

Matriculation Fee

Dissection Fee (including material for dissection)

Graduation Fee

ISo Fees for Lectures are required of third-course Students who have attended their

second course at the Bellevue Hospital Medical College.

FEES FOR THE SPRING SESSION.

Matriculation (Ticket valid for the following Winter)

Recitations, Cliuics and Lectures

Dissection (Ticket valid for the following Winter)

and

$140 CO
70 00

.t 00
10 00
30 00

$o 00
40 00
10 00

For the Annual Circular and Catalogue, giving regulations for graduation and other informa-
tion, address Prof. Austin Flint, Jr., Secretary, Bellevue Hospital Medical College.

304

American Journal of the Medical Sciences.

CHICAGO MEDICAL COLLEGE.

MEDICAL DEPARTMENT OF THE NORTHWESTERN UNIVERSITY.
Sessions of 1883-4.

H. A. JOHNSON, A.M., M.D.,
Emeritus Professor of the Principles and
Practice of Medicine and Clinical Medicine.

N. S. DAVIS, M.D:, LL D, Dean,
Professor of Principles and Practice of
Medicine and. of Clinical Medicine.

EDMUND ANDREWS, M D., LL.D.,
Professor of Clinical Surgery.

RALPH N. ISHAM, M.D ,
Professor of the Principles and Practice of
Surgery.

E. 0. F. ROLER, A.M., M.D.,
Professor of Obstetrics.
SAMUEL J. JONES, A.M., M.D.,
Professor of Ophthalmology and Otology.
J. H. HOLLISTER, M.D.,
Professor of Clinical Medicine.

J. S. JEWELL, A.M., M.D.,
Professor of Nervous and Mental Di eases.

MARCUS P. HATFIELD, A.M., M.D.,
Professor of Diseases of Children.
LESTER CURTIS, A.M., M.D.,
Professor of Histology.

HENRY GRADLE, M.D ,
Professor of Physiology.

E. C. DUDLEY, A.M , M D. ,

Professor of Gynaecology.

JOHN E. OWENS, M.D.,
Professor of Surgical Anatomy and
Operations of Surgery.

OSCAR C. DrWOLF, M.D.,
Professor of State Melicine and Hygiene.

J. H. LONG. M.D.,
Professor of General and Medical Chemistry.

WALTER HAY, M.D , LL D.,
Professor of Materia Medica and
Therapeutics.

F C. SCHAEFER, M.D.,
Professor of Descriptive Anatomy.

CHRISTIAN FENGER, M.D.,
Professor of Pathology and Pathological
Anatomy.

I. N. DANFORTH, A.M.; M.D.,
Professor of Clinical Medicine.

A. G. PAINE, M.D.,
Lecturer on Dermatology.

FRANK BILLINGS, M.D.,
Demonstrator of Anatomy.

The Collegiate Year in this Institution consists of a REGULAR AUTUMN AND WIN-
TER SESSION, and a special SESSION FOR PRACTITIONERS. THE REGULAR
SESSION begins September 25, 1883, and closes March 25, 1884.

This College was the first in the United States to adopt a graded system of instruction.
All applicants for admission must possess at least a good English education, and present
full evidence of the same. If an applicant has received the degree of A.B., or presents
a certificate from some reputable Scientific School, High School, or Academy, no matri-
culation examination will be required; otherwise he must sustain a satisfactory ex-
amination before a committee of the Faculty. The students are divided into 1st Year,
2o Year, and 3d Year Classes, instructions being given simultaneously in different
lecture rooms.

The Clinical advantages of this College, with the great number of Dispensary, College
Clinic and Hospital patients, cannot be surpassed. All professors of practical branches are
members of the staff of Mercy or Cook County Hospital, or other charities For several
sessions each senior student has had the privilege of attending upon one or more obstet-
rical cases, and of witnessing important obstetrical operations.

It is the aim of the Faculty to make all instruction in the College "pre-eminently prac-
tical.

THE PRACTITIONERS' COURSE, designed for Practising Physicians only, was in-
augurated in 18S0. It has proven so satisfactory to all concerned that it will be con-
tinued and constitute a portion of each Collegiate year. This course will begin the day
following the public Commencement exercises, and continue for four weeks, affording,
by means of didactic and daily clinical instruction, special advantages to physicians tor
a rapid, yet thorough, practical review of the most important su ejects in Medicine and
Surgery.

Fees for Collegiate Year (except Practitioners' Course), $75. Registration Fee,
$5. Demonstrator's Ticket, $5. Laboratory Ticket, $5. Mercy Hospital Ticket, $6.
Final Examination Fee, $30. For Practitioners' Course, including Laboratory, Ana-
tomical, and Hospital Tickets, $30.

For the Annual Announcement and Catalogue, or for any information relating to the
College, address

N. S. DAVIS, M.D., LL.D.,

65 Randolph St., Chicago, III.

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR OCTOBER, 18 83.

CONTRIBUTORS TO THIS VOLUME.

NISHAN ALTOUNIAN, M.D., of Turkey in Asia.

SAMUEL ASHHURST, M.D., Surgeon to the Children's Hospital, Philadelphia.
I. E. ATKINSON, M.D., Professor of Pathology in the University of Maryland.
LOUIS W. ATLEE, M.D., of Philadelphia, Pa.

EDWARD T. BRUEN, M.D., Demonstrator of Clin. Medicine in University of Penna.
C. B. BURR, M.D., Asst. Physician to the Eastern Michigan Asylum, Pontiac, Mich.
T. R. CHAMBERS, M.D., of Past Orange, N. J.
WILLIAM S. CHEESMAN, M.D., of Auburn, New York.

J. SOLIS COHEN, M.D., Professor of Laryngology in Jefferson Med. College, Phila.
SOLOMON SOLIS COHEN, A.M., M.D., Demonstrator of Pathology and Microscopy

in the Philadelphia Polyclinic.
P. S. CONNER, M.D., Professor of Anatomy and Clinical Surgery in the Medical

College of Ohio.

LOUIS A. DUHRING, M.D., Professor of Skin Diseases in the University of Penna.
CHARLES W. DULLES, M.D., Surgical Registrar, Hospital of the University of Penna.
ROBERT FLETCHER, M.R.C.S.E., of Washington, D. C.

H. HORACE GRANT, M.D., Lecturer on Operative and Minor Surgery in the Kentucky

School of Medicine.
PAUL GROSSMANN, M.D., of Omaha, Nebraska.

GEORGE C. HARLAN, M.D., Surgeon to the Wills [Ophthalmic] Hospital, Phila.

ROBERT P. HARRIS, M.D., of Philadelphia, Pa.

H. LAWRENCE JENCKES, M.D., of Glen Haven, Wis.

GEORGE WOODRUFF JOHNSTON, A.M., M.D., Senior Assistant House Surgeon in

the Woman's Hospital, New York City.
W. W. KEEN, M.D., Prof, of Surgery in the Woman's Medical College of Philada.
JOHN A. LIDELL, A.M., M.D., of New York.

JOHN N. MACKENZIE, M.D., Surgeon to the Baltimore Eye, Ear, and Throat Charity
Hospital.

READ J. McKAY, M.D., of Wilmington, Del.

J. EWING MEARS, M.D., Demonstrator of Surgery in Jefferson Medical College, Phila.
WALTER MENDELSON, M.D., of New York.'

MIDDLETON MICHEL, M.D., Professor of Physiology in the Medical College of South

Carolina, Charleston, S. C.
CHARLES K. MILLS, M.D., Professor of Diseases of the Mind and Nervous System in

the Philadelphia Polyclinic.
JAMES L. MINOR, M.D., Asst. Surgeon to the Nero York Eye and Ear Infirmary.
S. WEIR MITCHELL, M.D., Physician to the Infirmary for Nervous Diseases, Phila.
ROBERT B. MORISON, M.D., of Baltimore, Md.

WILLIAM P. NORTHRUP, M.D., Pathologist to the New York Foundling Asylum.
WILLIAM OSLER, M.D., Professor of Institutes of Medicine in McGill Univ., Montreal.
J. C. REEVE, M.D., of Datjton, Ohio.

JOSEPH P. REMINGTON, Ph.G., Professor of the Theory and Practice of Pharmacy

in the Philadelphia College of Pharmacy.
JOS. G. RICHARDSON, M.D., Professor of Hygiene in the University of Pennsylvania.
ROBERT PATERSON ROBINS, M.D., of Philadelphia.
W. S. W. RUSCHENBERGER, M.D., Surgeon U. S. Navy.
CHARLES SMART, M.D., Surgeon U. S. Army.

JAMES TYSON, M.D., Professor of General Pathology in the University of Pennsylvania.
ARTHUR VAN HARLINGEN, M.D., Professor of Skin Diseases in the Philadelphia
Polyclinic.

H. R. WHARTON, M.D., Demonstrator of Clinical Surgery in the University of Penna.
JAMES C. WHITE, M.D., Professor of Dermatology in Harvard University.
HIRAM WOODS, M.D., House Physician of Bay View Asylum, Baltimore.

TO READERS AND CORRESPONDENTS.

Contributors who wish their articles to appear in the next number are requested
to forward them before the 1st of November.

Liberal compensation is made for all articles used. Extra copies, in pamphlet
form with cover, will be furnished to authors in lieu of compensation, provided
the request for them he made at the time the communication is sent to the Editor.

The following works have been received for review : —

Zur Entstehung und Behandlung der Scrophulose und der Scrophulosen Erkran-
kungen der Sinnorgane. Von Dr. 6. Paulsex, von Hamburg. Berlin, 1883.

Quelques reflexions sur la Lithotritie Rapide, practiquee suivant la methode du Dr.
Bigelow. Par le Dr. Delefosse, etc. Paris, 1883.

Suture de la Vessie, pour une ti es grande plaie intra et extra Peritoneale. Repara-
tion en deux actes operatoires eloignes, Guerison. Par le Dr. S. Possi. Paris, 1883.

De l'Excisiou du Goitre Parenchytnatoux. Par le Dr. Liebrecht, Assistant a
l'Universite de Liege. Bruxelles, 1883.

L'Ospedale delle Donne e dei Bambini ; Relazioni del Dott. G. Berruti et dele'
Tug. 0. Ballati. Torino, 18S3.

Zur Lehre von der Lokalisation der Geliirnfunctionen. Yon Prof. Dr. Moritz
Bexedikt. Wien, 1883.

De TUrine dans l'Hematurie des Vaches. Par le Dr. Albert Robix. Paris, 1878.

Zur Physiologie de Gebbrsebnecke. Von Dr. B. Bagixsky. Sitzungsbericbte du
k. k. Akad. du Wissenschaften zu Berlin, 1883.

De la Production du Phenol dans l'Organisme, considered au point de vue physio-
logique et clinique. Par le Dr. Albert Robix, etc. Paris, 1883.

Note sur une Cause de la Litbiase imque et oxalique chez les enfants du premier
age. Diagnostic et Traitement. Par le Dr. Albert Robix. Paris, 1883.
"Guy's Hospital Reports. Edited bv H. G. Howse, M.S., and Frederick Taylor,
M.D. Vol. XLI. London : J. & A. Churchill, 1883.

Hospitals, Infirmaries, and Dispensaries : Their Construction, Interior Arrangement,
and Management. With seventy-four illustrations. By F. Oppert, M.D. , M.R.C.P.L.
Second (English) edition, revised and enlarged. London : J. & A. Churchill, 1883.

The Pharmacopoeia of the Xorth-Eastern Hospital for Children. As compiled bv a
Committee of the Staff. London : J. & A. Churchill, 1883.

Some Recent Advances in the Surgery of the Urinary Organs. By Regixald Har-
risox, F.R.C.S., etc. London : J. & A. Churchill, 1883, pp. 30.

Lead Poisoning. By Thomas Stevexsox, M.D.

Poisoning by Aconite (case of Reg. v. Lamson). By Thomas Stevexsox, M.D.
The Causation of Sleep. By James Cappie, M.D. Second edition. Edinburgh:
James Thin, 1882,

A Treatise on Diseases of the Eye. By J. Soelsberg Wells, F.R.C.S., Professor
of Ophthalmology in King's College, etc. Fourth American from the third English
edition, with copious additions. By Charles Steadman Bull, A.M., M.D., etc.
Philadelphia : Henry C. Lea's Son & Co., 1883.

Anatomy, Descriptive and Surgical. By Hexrt Gray, F.R.S., F.R.C.S, etc. etc.
With an Introduction on General Anatomy and Development. By Timothy Holmes,
M.A., Cantab., etc. etc. Edited by T. Pickerixg Pick, Surgeon to St. George's
Hospital, etc. A new American from the tenth English edition. To which is added
Landmarks, Medical and Surgical. By Luther Holdex, F.R.C.S. With additions.
By W. W. Keex, M.D. Philadelphia : Henry C. Lea's Son & Co., 1883.

Elements of Histology. By E. Kleix, M.D., F.R.S., etc. Philadelphia : Henry C.
Lea's Son & Co., 1S83.

The Treatment of Wounds and Fractures : Clinical Lectures. By Sampsox Gam-
gee, F.R.S.E., etc. Second edition. Philadelphia: P. Blakiston, Son & Co., 1883.

Practical Histology and Pathology. By Hexxeage Gibbes, M.D., etc. Second
edition. Philadelphia : P. Blakiston, Son & Co., 1883.

A Pocket-Book of Physical Diagnosis of the Diseases of the Heart and Lungs. By
Dr. Edward T. Bruex, one of the" Ph vsicians to the Philadelphia Hospital, etc. Phila-
delphia : P. Blakiston, Son & Co., 1883.

312

TO READERS AND CORRESPONDENTS.

Enteric Fever : Its Prevalence and Modifications ; Etiology, Pathology, and Treat-
ment, as illustrated by Army Data at Home and Abroad. Bv Francis H. Welch,
F.R.C.S., Surgeon-Major, A. M.D. Philadelphia : P. Blakiston, Son & Co., 1883.

The Principles and Practice of Surgery. Being a Treatise on Surgical Diseases and
Injuries. By D. Hayes Agnew, M.D., LL.D., Professor of Surgery in the University
of Pennsylvania. Vol. III. Philadelphia : J. B. Lippincott & Co. 1883.

The Roller Bandage. By Wm. Barton Hopkins, M.D., etc. With seventy-three
illustrations. Philadelphia : J. B. Lippincott & Co., 1883.

Hand-book of Electro-therapeutics. Dy Dr. Wilhelm Erb, Prof, in University of
Leipzig. Translated by L. Putzel, M.D. New York : Wm. Wood & Co., 1883.

Text-Book of Pathological Anatomy and Pathogenesis. By Ernst Zeigler, Pro-
fessor of Pathological xinatomy in the University of Tubingen. Translated by Donald
MacAlerton, M.A., M.B., etc. New York, 1883.

Types of Insanity. An Illustrated Guide in the Physical Diagnosis of Mental Dis-
eases. By Allan McLane Hamilton, M.D., etc. New York : Wm. Wood & Co.,
1883.

The Treatment of Wounds : Its Principles and Practice, Ceneral and Special. Bv
Lewis S. Pilcher, A.M., M.D., etc. New York : Wm. Wood & Co., 1883.

A Practical Treatise on the Medical and Surgical Uses of Electricity. By George
M. Beard, A.M., M.D., etc. etc., and A. D. Rockwell, A.M., M.D., etc. etc. Fourth
edition. New York : Wm. Wood & Co., 1883.

The Essentials of Bandaging, with Directions for Managing Fractures and Disloca-
tions ; for Administering Ether, Chloroform, and using other Surgical Apparatus.
By Berkely Hill, M.B. Lond., F.R.C.S., etc. Fifth edition. Revised and enlarged.
New York : J. H. Vail & Co., 1883.

Photo-Micrographs, and how to make them. By George M. Sternberg, M.D.,
F.R.M.S., etc. Boston : James R. Osgood & Co., 1883.

Excision of the Knee-Joint, with report of twenty-eight cases. By George Edge-
worth Fenwick, M.D., CM., etc. Montreal : Dawson Brothers, 1883.

History of Tuberculosis from the time of Sylvius to the present day. Being in part
a translation, with notes and additions, from the German of Dr. Arnold Spina, etc.
etc. By Eric E. Sattler, M.D. Cincinnati : Robert Clarke & Co., 1883.

A New School Physiology. .By Richard J. Dunglison, A.M., M.D., etc. 8vo.
pp. 315. Philadelphia : Porter & Coates, 1883.

Hand-book for Hospitals, No. 32. State Charities Aid Association. New York : G.
P. Putnam's Sons, 1883.

Lessons in Qualitative Chemical Analysis. By F. Beilstein, Professor at the Im-
perial Institute of Technology of St. Petersburgh. Translated from the fifth edition,
with copious additions, including lessons in organic and volumetric analysis. By
Charles O. Curtman, M.D., Professor of Chemistry in the Missouri Medical College,
and in the St. Louis College of Pharmacy. St. Louis, 1883.

Report on Diseases of Women from the First Congressional District. By R. J.
Nunn, M.D. Savannah, Ga.

Deafness among School Children. By Dr. J. P. Worrell.

Hydrops Chorii. By John Morris, M.D., Baltimore.

The Operative Treatment of Hare-lip. By James Whitson, M.D., F.F.P. and S.G.,
F.R.M.S., etc.

A Tracheotomy Tube for Gradual Withdrawal, and Report of a Case in which it was
used. By H. F. Hendrix, M.D., of St. Louis.

A Case of Adeno-Sarcoma of Mamma ; Removal of Growth ; Recovery. By James
Whitson, M.D., F.F.P. , S.G., etc.

A Rectal Obturator. By David Prince, M.D., of Jacksonville, 111.

The Treatment of the various forms of Acne. By George H. Rohe, M.D., etc,

Hints on the Treatment of some Parasitic Skin Diseases. By George H. Rohe,
M.D., etc., 1883.

Anatomy, Surgery, and Hygiene of the Rectum. By Joseph Eastman, M.D., etc.

A Peculiar Cutaneous Lesion (Ulcus Elevatum) occurring during the use of Bro-
mide of Potassium. By E. C. Seguin, M.D. New York, 1883.

Myelitis following Acute Arsenical Poisoning (by Paris or Schweinfurth Green).
By E. C. Seguin, M.D., etc.

Hysterical Convulsions and Hemianesthesia in an Adult Male. Cure by Metallo-
therapy. Gold. By E. C. Seguin, M.D., etc.

A Contribution to the Treatment of Empyema. By A. T. Cabot, A.M., M.D., etc.,
of Boston.

Jequirity Ophthalmia. By S. Pollak, M.D., of St. Louis.

The Bead Suture. A Modification of the Quilled Suture for Palatoplasty, and for
other operations. By David Prince, M.D., of Jacksonville, 111.

Experimental Researches on the Tension of the Vocal Bands. By F. H. Hooper,
M.D., etc., Boston.

Pemphigus, and the Diseases liable to be mistaken for it. By George H. Rohe,
M.D., etc., Baltimore.

TO READERS AND CORRESPONDENTS.

313

Some Researches after Haemoglobin. By Robert Saunders Henry, A.M., M.D.,
of Baltimore.

The Treatment of Retained Placenta after Abortion. By Hiram Von Schwering,
M.D., Fort Wayne, Ind.

Judicial Oaths and their Effect. Pp.8. Philadelphia, 1883.

The Next Step for the Medical Profession of the United States. By D. B. St. John
Roosa, M.D. , LL.D. New York, 1883.

Contribution to the Study of Neglected Lacerations of the Cervix Uteri and Peri-
neum. By Thomas A. Ashby, M.D., etc. Baltimore, 1883.

Opinion as to the Legality of Quarantine Laws of Louisiana. By F. C. Zacharie,
Attorney of Board of Health, State of Louisiana.

Report of Conference Committee of Louisiana Board of Health, relative to Proposi-
tion of New Orleans Auxiliary Association. Also report of Hon. F. C. Zacharie, At-
torney, on Ordinance 216 Council Series.

Outline of the History, Theory, and Practice of Quarantine, etc. By Joseph Jones,
M.D., President of the Louisiana State Board of Health. New Orleans, 18S3.

Registration of Physicians of the State of Louisiana, under Act 31 of 1882. New
Orleans, 1883.

The Topographical Relations of the Female Pelvic Organs. By Ambrose L. Ram-
set, A.M., M.D., etc. With twenty-two wood-cuts. Pp. 121. New York : Wm. Wood
& Co., 1883.

Extirpation of the Uterus. By Paolo De Vecchi, M.D., Torino, Italy. Also note
on Extirpation of the Kidney. San Francisco, 1883.

Transactions of the Medical Society of North Carolina and North Carolina Board of
Health. Concord, 1883.

Transactions of the Medical Society of West Virginia. Wheeling, 1883.

Transactions of the Mississippi State Medical Association. Meridian, April, 1883.

Transactions of the South Carolina Medical Association. Charleston, 1883.

Transactions of the College of Physicians of Philadelphia. Third series. Volume
VI. Pp. 451. Philadelphia, 1883.

Transactions of the State Medical Society of Tennessee, 1883. Nashville, 1883.

Transactions of the Michigan State Medical Society for the year 1883. Lansing, 1883.

Medical Communications of the Massachusetts Medical Society. Vol. XIII. , No. II.
1883. Boston, 1883.

Proceedings of the N. W. Provinces and Oudh Branch of the British Medical Associ-
ation, April to July, 1883.

Minutes of the Twenty-eighth Annual Meeting of the Kentucky State Medical
Society. Held at Louisville, April 4, 5, and 6, 1883.

Proceedings of the Medical Society of the County of Kings, New York. No. 7. 1883.

Proceedings of the Academy of Natural Sciences of Philadelphia. Part I. January
to May, 1883. Philadelphia, 1883.

Sanitary and Statistical Report of the Surgeon-General of the Navy, for the year
1881.

First Report of the State Board of Health to his Excellency, Thomas J. Churchill,
Governor of the State of Arkansas. From the organization, April 27, 1881, to Decem-
ber 1, 1882.

Report of the Proceedings of the Illinois State Board of Health. Quarterly meeting,
Springfield, June 29, 1883.

Twenty-eighth Annual Report upon the Births, Marriages, and Deaths in the City
of Providence, for the year 1882. By Edwin M. Snow, M.D., Superintendent of
Health and City Registrar. Providence, 1883*

Fifth Annual Report of the State Board of Health of Rhode Island, for the year
1882. Providence, 1883.

First Annual Report of the State Board of Health of New Hampshire, for the year
ending April 30, 1882. Concord, 1882.

Joint Annual Report of the Chamber of Commerce and Board of Trade of Minnea-
polis, Minnesota, 1882.

Report of the Commission de Lunatico Quirendo of Victor Eloi to the Hon. W. T.
Houston, Judge Civil District, Section B. By Y. R. Le Monnier, M.D., June, 1883.
New Orleans.

Report of the Department of Health, City of Chicago, for 1881 and 1882.

Report of the Board of Health of the City of Boston, for 1882-1883. Boston, 1883.

Report of the Trustees of the City Hospital, Boston, etc., 1882-1883. Boston, 1883.

Report on Laceration of the Cervix Uteri. By T. B. Harvey, M.D., etc.,, to the
Indiana State Medical Society, May, 1883.

Sixth Annual Report of the Managers of the Adams Nervine Asylum. Boston, 1883.

Report of the Board of Health of the State of Louisiana to the General Assembly,
for the year 1882, and the first six months of 1883. Embracing the Quarantine and
Sanitary Operations of the Board of Health during a period of eighteen months, Janu-
ary 1, 1882, to July 1, 1883. Baton Rouge, 1883.

314 TO READERS AND CORRESPONDENTS.

The following Journals have been received in exchange : —

Bibliothek forLseger. NordisktMedioinskt Arkiv. Upsala Lakareforenings Fb'rhand-
lingar. Kronika Lekarska. Annali Universali di Medecina e Chirurgia. Gazzetta
degli Ospitali. Giornale Italiano delle Malattie Veneree. El Ensayo Medico. LTndi-
pendente. L'Imparziale. Lo Sperimentale. O Correio Medico de Lisboa. Gazette
Med. de l'Orient. Cronica Medico-Quirurgica de la Habana. Uniao Medica. La
Union Medica, Caracas. Allgemeine Wiener Medizinische Zeitung. Berliner Kli-
nische Wochenschrift. Centralblatt fiir die Gesammte Therapie. Centralblatt fur
Chirurgie. Centralblatt fur Gynakologie. Centralblatt fiir Klinische Medicin.
Centralblatt fiir die Medicinischen Wissenschaften. Deutsches Archiv fiir Klinische
Medicin. Deutsche Medicinische Wochenschrift. Medicinisch-Chirurgisch Central-
blatt. Medizinische Jahrbiicher. Wiener Med. Presse. Zeitschrift fur Physiologische
Chemie. Annales de Dermatologie et de Syphiligraphie. Anuales de Gynecologic
Annales des Maladies de l'Oreille, du Larynx, et des Organes Annexes. Archives de
Medicine et de Pharmacie Militaires. Archives de Neurologic Archives Generates
de Medecine. Bulletin Generale de Therapeutique. Gazette Hebdomadaire. Gazette
Medicale de Paris. Gazette Medicale de Nantes. Journal de Medecine de Paris.
L'Abeille Medicale. L'Encephale. Le Progres Medicale. L'Union Medicale. Revue
de Chirurgie. Revue de Medecine. Revue de Therapeutique. Revue des Sciences
Medicales. Revue Internationale des Sciences Biologiques. Revue Med. Franc, et
Etrangere. Revue Mensuelle de Laryngologie. Revue Scientifique. Brain. Braith-
waite's Retrospect. Bristol Medico-Chirurgical Journal. British Medical Journal.
Dublin Journal of Medical Science. Edinburgh Medical Journal. Glasgow Medical
Journal. Journal of Anatomy and Physiology. Journal of Physiology. Journal of
Psychological Medicine. Lancet. Liverpool Medico-Chirurgical Journal. London
Medical Record. Medical Times and Gazette. Ophthalmic Review. Practitioner.
Australian Medical Journal. Indian Medical Gazette.

American Psychological Journal. Archives of Laryngology. Atlanta Medical
Register. Atlantic Journal of Medicine. Alienist and Neurologist. American Journal
of Insanity. American Journal of Neurology and Psychiatry. American Journal of
Obstetrics. American Journal of Otology. American Journal of Pharmacy. Ameri-
can Journal of Science. American Medical Digest. American Practitioner. Annals
of Anatomy and Surgery. Archives of Medicine. Archives of Ophthalmology. Ar-
chives of Otology. Atlanta Medical and Surgical Journal. Boston Medical and Surgi-
cal Journal. Boston Journal of Chemistry. Buffalo Medical and Surgical Journal.
Chicago Medical Journal and Examiner. Chicago Medical Review. Cincinnati Lancet
and Clinic. Cincinnati Medical News. College and Clinical Record. Columbus Medi-
cal Journal. Denver Medical Times. Detroit Lancet. Detroit Clinic. Druggists'
Circular. Ephemeris of Materia Medica. Gaillard's Medical Journal. Hall- Yearly
Compendium of Medical Science. Journal of Cutaneous and Venereal Diseases.
Journal of Nervous and Mental Diseases. Journal of the American Medical Associa-
tion. Kansas Medical Index. Louisville Medical News. Maryland Medical Journal.
Medical Age. Medical Gazette. Medical Herald. Medical Annals. Michigan Medi-
cal News. Medical News. Medical and Surgical Reporter. Medical Record. Missis-
sippi Valley Medical Monthly. Nashville Journal of Medicine and Surgery. New
Orleans Medical and Surgical Journal. New Remedies. New York Medical Journal.
North Carolina Medical Journal. Obstetric Gazette. Ohio Medical Journal. Pacific
Medical and Surgical Journal. Pittsburg Medical Journal. Philadelphia Medical
Times. Polyclinic. Rocky Mountain Medical Times. Physician and Surgeon. San
Francisco Western Lancet. Sanitarian. St. Louis Clinical Record. St. Louis Courier
of Medicine. St. Louis Medical and Surgical Journal. Therapeutic Gazette. Vir-
ginia Medical Monthly. Canadian Practitioner. Canada Lancet. Canada Medical
Record. Canada Medical and Surgical Journal. L'Union Medicale du Canada. Medi-
cal Age. Sanitary Engineer. Sanitary News.

Communications intended for publication, and books for review, should be sent
free of expense, directed to I. Minis Hays, M.D., Editor of the American Journal of the
Medical Sciences, care of Henry C. Lea's Son & Co., Philadelphia. Parcels directed as
above, and (carriage paid) under cover, to Messrs. Nimmo & Bain, Booksellers, No. 14
King William Street, Charing Cross, London, will reach us safely and without delay.

All remittances of money and letters on the business of the Journal should be ad-
dressed exclusively to the publishers, Henry C. Lea's Son & Co., No. 706 Sansom Street.

The advertisement sheet belongs to the business department of the Journal, and all
communications for it must be made to the publishers.

CONTENTS

THE AMEBIC AN JOURNAL

THE MEDICAL SCIENCES.

NO. CLXXII. NEW SERIES.

OCTOBER, 1883.

ORIGINAL COMMUNICATIONS.
MEMOIRS AND CASES.

ART. PAGE

I. On certain Abscesses of the Neck -which may Cause Sudden Death, and
how to Treat them with Success. By John A. Lidell, A.M., M.D., of
New York, late Surgeon to Bellevue Hospital, etc. .... 321

II. A Contribution to the General Knowledge concerning the Prurigo
Papule. By Robert B. Morison, M.D., of Baltimore .... 341

III. Excision of the Tarsus, with a Report of Two Successful Removals of
the Entire Tarsus. By P. S. Conner, M.D., Prof, of Anatomy and
Clinical Surgery, Medical College of Ohio, etc. ..... 362

IV. On the Renal Circulation during Fever. An Experimental Research
made at the Pathological Institute of the University of Leipzig. To
which was awarded the Cartwright Prize Essay for 1883. By Walter
Mendelson, M.D., of New York . . 380

V. Calculous and other Affections of the Pancreatic Ducts. By George
Woodruff Johnston, A.M., M.D., Senior Assistant House Surgeon in
the Woman's Hospital, New York City: late House Surgeon in the
Hospital of the University of Pennsylvania, Philadelphia . . . 404

VI. Classification of the "Porro (?) Operations." What is a True Porro-
Csesarean Operation, and what other Forms of Uterine Ablation in
Pregnant Women have been erroneously called "Porro," and should be
separately classified. By Robert P. Harris, A.M., M.D., of Philadelphia 430

VII. Ligation of the Subclavian Artery between the Scaleni for Hemor-
rhage from a Gunshot Wound. Recovery. By Middleton Michel, M.D.,
Professor in the Medical College of the State of South Carolina, Charles-
ton, S. C . .439

VIII. Galvano-Puncture for the Cure of Aneurism. By T. R. Chambers,
M.D., of East Orange, N. J 447

316

CONTENTS.

ART. PAGE

IX. Closure of the Jaws and its Treatment, with the report of a case in
which complete occlusion followed a Gunshot Wound of the Left Superior
Maxilla, received at two arid a half years of age, and which was relieved
eighteen years subsequently by operation according to a new method. By
J. Ewing Mears, M.D., Professor of Anatomy and Clinical Surgery in
the Pennsylvania College of Dental Surgery, Demonstrator of Surgery

in Jefferson Medical College, etc. ........ 454

X. Report of a Case of Abscess of the Left Iliac Fossa, with some Remarks.

By Louis W. Atlee, M.D., of Philadelphia 4G3

XI. Clinical Observations upon Otorrhcea (Chronic Purulent Otitis Media),
with Perforations of the Membrana Tympani. By Read J. McKay,
M.D., of Wilmington, Delaware, Member of the American Otological
Society 468

XII. A Modified Porro-Cajsarean Operation: The Pedicle Dropped in.

By Paul Grossmann, M.D., of Omaha, Nebraska . . . . .477

XIII. Experiments in the Use of Naphtol for the Treatment of Skin Dis-
eases. By Arthur Van Harlingen, M.D., Professor of Skin Diseases in
the Philadelphia Polyclinic . . . . . . . . .479

XIV. Periostitis of the Mastoid ; Necrosis ; Recovery. By Wm. S. Chees-
man, M.D., of Auburn, New York 490

REVIEWS.

XV. Spinal Concussion.

Injuries of the Spine and Spinal Cord without Apparent Mechanical
Lesion and Nervous Shock, in their Surgical and Medico-Legal Aspects.
By Herbert W. Page, M.A., M.C. Cantab., Fellow of the Royal Col-
lege of Surgeons of England, etc. Philadelphia: P. Blakiston, Son
& Co., 1-883 493

XVI. Saint Thomas's Hospital Reports. New Series. Edited by Dr.
Robert Corey and Mr. Francis Mason. Vol. XL 8vo. pp. xvi., 419.
London: J. & A. Churchill, 1882 . . . . • . . . .503

XVII. Guy's Hospital Reports. Edited by H. G. Howse, M.S., and
Frederick Taylor, M.D. Vol. XLL, pp. 515. London: J. .& A.
Churchill, 1883 512

XVIII. Sanitary and Statistical' Report of the Surgeon-General of the Navy
for the year 1881. 8vo. pp. 684. Government Printing Office, Wash-
ington, D. C, 1883 517

XIX. A Treatise on Insanity in its Medical Relations. By William A.
Hammond, M.D., Surge on- General United States Army (Retired List) ;
Professor of Diseases of the Mind and Nervous System in the New York
Post-Graduate Medical School ; President of the American Neurological
Association, etc. 8vo., 767 pages. New York: D. Appleton & Co.,
1883 . . . . ' . . . . . . . . . .521

CONTENTS.

317

ART. "w PAGE

XX. Chirurgie Orthop6dique. Therapeutique des DifFormit6s congenitales
ou acquis6s. Par le Dr. L. A. Saint-Germain, Chirurgien de l'Hopital
des Enfants-malades. 8vo. pp. 7, 651. Avec figures. Paris: J. B.
Balliere et Fils, 1883.

Orthopaedic Surgery. Treatment of Congenital and Acquired Deformities.
By Dr. L. A. Saint-Germain, etc 525

XXI. A Text-book of Pathological Anatomy and Pathogenesis. By Ernst
Ziegier, Prof, of Pathological Anatomy in the University of Tubingen.
Translated and edited for English students by Donald MacAlister, M.A.,
M.B., Member of the Royal College of Physicians, Fellow and Medical
Lecturer of St. John's College, Cambridge. Part I. General Patho-
logical Anatomy, pp. 360, figs. 117. London: Macmillan & Co., 1883 . 527

XXII. The Transactions of The Medico- Chirurgical Society of Edinburgh.
Vol. I. Session 1881-2. 8vo. pp. 188. Oliver and Boyd, Publishers

to the Society, Edinburgh, 1882 529

XXIII. A History of Tuberculosis from the time of Sylvius to the present
day, being in part a translation, with Notes' and Additions, from the German
of Dr. Arnold Spina ; containing also an Account of the Researches and
Discoveries of Dr. Robert Koch and other recent Investigators. By Eric
E. Sattler, M.D. 12mo. pp. 191. Cincinnati: Robert Clarke & Co.,
1883 • . . . .530

XXIV. Disease Germs.

1. The Bacteria. By Dr. Antoine Magnin, Licentiate of Natural Sci-

ences, Chief of the Practical Labours in Natural History to the
Faculty of Medicine of Lyons, etc. Translated by George M. Stern-
berg, M.D., Surgeon U. S. Army. 8vo. pp. 227. Boston: Little,
Brown & Co., 1880.

2. Bacteria: the smallest Living Organisms. By Dr. Ferdinand Cohn.

Translated by Dr. Charles S. Dolley. Pamphlet, pp. 30. Roches-
ter, N. Y.

3. Bacteria and the Germ Theory of Disease ; Eight Lectures delivered

at the Chicago Medical College. By Dr. H. Gradle, Prof, of Phy-
siology, Chicago Medical College. 8vo. pp. 219. Chicago: W. T.
Keener, 1883.

4. On the Relations of Micro- Organisms to Disease. The Cartwrio-ht

Lectures delivered before the Alumni Association of the College of
Physicians and Surgeons, New York. By William T. Belfield,
M.D., Lecturer on Pathology and on Genito-Urinary Diseases, Rush
Medical College, Chicago. 16mo. pp. 131. Chicago: W. T.
Keener, 1883 . . ... . . . . . . 531

XXV. De 1' Excision du Goitre Parenchymateux. Par Le docteur Paul
Liebrecht, Assistant a 1' Universite de Liege, Ext. du Bulletin de
l'Academie Royale de M6decine de Belgique; 3e Ser., t. xviii., No. 3.
8vo. pp. 270. Bruxelles: H. Manceaux, 1883.

The Excision of. Parenchymatous Goitre. By Dr. Paul Liebrecht, etc. . 532

318

CONTENTS.

ART. PAGE

XXYI. Health Reports.

1. First Annual Report of the Board of Health of the State of New

Hampshire for the year ending April 30, 1882. Concord, 1882,
pp. 318.

2. Fifth Annual Report of the Board of Health of the State of Rhode

Island for 1882. Providence, 1883. Pamphlet, pp. 327.

3. First Report of the State Board of Health of Arkansas from April,

1881, to December, 1882. Little Rock, 1883. Pamphlet, pp. 181 535

XXVII. Excision of the Knee- Joint, with Report of twenty-eight Cases.
Illustrated by thirteen Photo-Lithographs and Wood Engravings. By
George Edgeworth Fenwick, M.D., CM., etc. 8vo. pp. G8. Montreal:

Dawson Bros., 1883 .......... 538

XXVIII. Types of Insanity: An Illustrated Guide in the Physical Diag-
nosis of Mental Disease. By Allen McLane Hamilton, M.D., one of the
Consulting Physicians to the Insane Hospitals of New York City, etc.
New York: William Wood & Co., 1883 540

XXIX. On the Treatment of Wounds and Fractures; Clinical Lectures.
By Sampson Gamgee, F.R.S.E., etc. Second edition, 8vo., pp. ix.,
364. With 44 engravings on wood. Philadelphia: P. Blakiston, Son &
Co., 1883 540

XXX. Handbook of Electro-Therapeutics. By Dr. Wilhelm Erb, Pro-
fessor in the University of Leipzig. Translated by L. Putzel, M.D.
With thirty-nine wood-cuts. 8vo. 366 pages. New York : Wm. Wood

& Co., 1883 545

XXXI. Observations on Lithotomy, Lithotrity, and the early Detection of
Stone in the Bladder; with a Description of a New Method of Tapping
the Bladder. By Reginald Harrison, F.R.C.S., etc. 8vo. pp. 71.
London: J. & A. Churchill, 1883 545

XXXII. Anatomy, Descriptive and Surgical. By Henry Gray, F.R.S.,
with the collaboration of T. Holmes, M.A., H. V. Carter, M.D., and T.
Pickering Pick. A new American, from the tenth English edition, to
which is added Landmarks, Medical and Surgical, by Luther Holden,
F.R.C.S., with additions by W. W. Keen, M.D., Svo. pp. xxxii., 1023.
Philadelphia: Henry C. Lea's Son & Co., 1883 546

CONTENTS.

319

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

Anatomy and Physiology.

page

Primary Radicles of the Lymphatic
System. By M. Sappey . . 547

A New Centre of Vision in the
Human Eye. By M. Delboeuf 548

PAGE

Kymographic Measurements in
Men. By Prof. E. Albert . 549

Physiology of the Bladder and
Rectum. By Mr. F. Le Gros
Clark . . . . .550

Materia Medica and Therapeutics.

Physiological Action of Barium
Chloride. By Drs. Sidney Rin-
ger and Harrington Sainsbury . 550
Action of Saline Cathartics. By

Mr. Matthew Hay . . .551
Action of Piperidin. By Fliess . 553
Iodoform. By Dr. Hofmakl . 554
Anaesthetic Action of a Mixture of
Air and Chloroform. By M.
Paul Bert . . . .555

Value of Hyoscyamine in Psychia-
tric Practice. By M. Gnauk .

Acetal and Paraldehyde ; their
Hypnotic and Analgesic Proper-
ties. By von Mering

Resorcin in Hyperpyrexia, Inter-
mittent Fever, Anthrax, and
Erysipelas .

556

. 556

558

Medicine.

Hasmoglobinaemia. By Prof. Pon
fick . . . .

Renal Form of Typhoid Fever.
By Dr. Didion

Treatment of Cholera. By Dr. B.
Ward Richardson

Diabetes in Children. By Dr. Sen-
ator . . . . .

Melituria after Scarlatina. By Dr.
Zinn .

Acetonuria and Diabetic Coma.
By S. Mackenzie

Resorcin in Whooping- Cough. By
Dr. Moncorvo .

Pathology of Bronchial Asthma.
By Prof. Riegel

Fatty Transformation of the Kid-
ney. By Mr. Edwin Rickards

. 559

560

561

562

563

. 564

565

567

Adenoma of the Kidney. By Drs.
A. Weichselbaum and Robert
W. Greenish . . . .568

The Nature of the Albuminuria of
Bright' s Disease. By Dr. Sem-
mola ..... 570

Relation between Serum- Albumen
and Globulin in Albuminuria.
By Prof. F. A. Hoffman . . 572

Haemato-Chyluria and Chyluria.
By Wucherer . . . .573

Treatment of Leprosy. By Sur-
geon-Major Peters . . .574

Value of Arsenic in Certain Forms
of Ansemia. By Dr. F. W.
Warfvinge . . . .576

320

CONTENTS.

Surgery.

PAGE

Operative Procedures in Diseases
of the Lungs. By Dr. Bull . 578

Ulcer of the Duodenum. By Dr.
Chvostek 579

Resection of the Intestine. By
MM. G. Bouilly and G. Assaky 583

PAGE

Resection of the Intestine. By

Dr. Teresino Prati . . . 584
Inguino-properitoneal Hernia. By

Dr. Max Oberst . . . 584
Removal of Large Renal Tumour

by Abdominal Section. By Dr.

Henry G. Rawdon . . . 585

Ophthalmology and Otology.

Dilute Solutions of Eserine in
Weakness of the Ciliary Muscle.
By Dr. John C. Uhthoff .

Trephining the Pyramid of the
Petrous Bone. By Gluck . 58 7

Midwifery and Gynaecology.

Extra-uterine Pregnancy. By
Prof. A. L Krassowski . . 588

Metria. By Drs. Lombe Atthill,
Thomas Moore Madden, Alex-
ander, Wynn Williams, A. D.
Macdonald, Ed is, and Graily
Hewitt 588

Dysmenorrhea. By Dr. Vedeler 594

Pathology and Treatment of Ute-
rine Myoma. By Mr. Lawson
Tait and Drs. Herman, Dewar,
and Meadows .... 596

Accumulations of Pus in the Ute-
rus. By Prof. N. F. Tolochinofl' 597

Puerperal Inversion of the Uterus.
By Prof. Braun . . .598

Medical Jurisprudence and Toxicology.

Diffusion of Arsenic through the Body when thrown into the Mouth and
Rectum after Death. By Prof. Prescott and Drs. Vaughan and Dawson . 599

THE

AMERICAN JOURNAL
OF THE MEDICAL SCIENCES

FOR OCTOBER 1883.

Article I.

On certain Abscesses of the Neck which may Cause Sudden Death,
and how to Treat them with Success. By John A. Lidell, A.M.,
M.D., of New York, late Surgeon to Bellevue Hospital, etc.

. Many years ago, an example of very sudden death, which resulted from
a small and seemingly a circumscribed abscess of the connective tissue
that had been rather rapidly developed underneath the left sterno-cleido-
mastoid muscle, came under my notice and impressed me so strongly at the
time, that its remembrance has never become effaced, nor even much im-
paired. This example I have long intended to record in a permanent
form, but circumstances, which it is now unnecessary to mention, have
hitherto prevented. However, I shall proceed without any further delay
to execute this ancient purpose.

My attention was first called to the case on Sunday morning, July 24,
1864, at the usual weekly inspection of Stanton Military Hospital (which
was then under my charge), by Dr. John B. Garland, Acting Assistant
Surgeon U. S. Army, who had the immediate care of the young man who
was the patient. He was sitting in a chair at the time, beside the head of
his bed, in Ward No. 5 ; but, when 1 approached him, he immediately
arose and gave the usual military salute, without showing any sign of
physical weakness. His countenance was .rather pale ; but it did not ap-
pear to be emaciated, nor indicative of any particular suffering or disease.
There was, however, a tumefaction plainly visible on the left side of his
throat, first noticed only three days before, that was increasing steadily
and rather rapidly, which made Dr. Garland somewhat anxious about the
case, and desirous of my advice, especially in regard to the nature or diag-
No. CLXXIL— Oct. 1883. 21

322

Lid ell, Abscesses of the Neck.

[Oct.

nosis of the tumefaction itself. His neck was stiff, and his head twisted
somewhat toward the opposite side. Proceeding now to examine the pa-
tient manually (chirurgically), I found on the left front of his neck, at the
level of the pomum Adami, a pretty firm and well-rounded, but not mov-
able swelling, about the size of a small lemon, which was deeply seated,
being apparently in or near the track of the great cervical bloodvessels
and pneumogastric nerve of that side, and obviously covered by the sterno-
cleido-mastoid muscle, as well as by the common integument, etc. It ex-
hibited an obscure deeply-seated fluctuation, but was entirely destitute of
pulsation ; it also exhibited some tenderness (soreness) under pressure.

As to the young man's previous history, I was briefly informed that
he had been admitted into the hospital somewhat over two months
previously for a gonorrhoea, which had readily yielded to the treatment
employed ; that, while waiting in the hospital to regain his strength,
he had been attacked with cynanche tonsillaris and malarial fever,
which proved rather obstinate, but finally they were overcome ; and that,
while he was convalescing from these disorders, diarrhoea supervened,
and was followed by the tumefaction mentioned above, which first pre-
sented itself, in company with some soreness and stiffness of the affected
parts, three days before, as already stated. I was also informed that there
had not been any cutaneous eruption in the history of the case, nor any
osteocopes, nor any enlargement of the lymphatic ganglia in the neck,
groins, elbows, or any other part, although it had been repeatedly and
carefully sought for. There certainly was no sign of syphilis discernible
when I saw him. Finally, I concluded that the swelling on the left front
of his neck was an abscess formed in the deep connective tissue of his
neck, and firmly bound down by the reduplications of the deep cervical
fascia, which should be promptly opened and evacuated by making an ex-
ternal incision ; but, as there was not much dysphagia, and no dyspnoea
whatever, as well as not even the slightest symptom apparent indicating
any urgency for the immediate employment of this procedure, and, more-
over, being myself much pressed for time by reason of the inspection then
in hand, I unwittingly postponed the operation of incising it until the fol-
lowing morning. Indeed, the patient expressed himself in reply to my
inquiry as feeling quite comfortable ; and certainly there was nothing
whatever to be seen among the objective signs which could lead one to
suspect that a fatal issue of the case might be very close at hand. That
evening, however, I was surprised and shocked on learning that the
patient had suddenly expired in the afternoon, from asphyxia caused by a
tight closure of the rima glottidis, without the appearance of any warning
symptoms, and before the officer of the day could be brought to him.

With good reason, then, Dr. Garland had exhibited unusual anxiety
concerning his patient's welfare ; not only because, as he said, the man
had been in the hospital somewhat over two months, firstly for gonorrhoea,

1883.]

Lid ell, Abscesses of the Neck.

323

next for tonsillitis, ulcerated sore-throat, and malarial fever, then for diar-
rhoea, and finally a deep-seated abscess in the neck had suddenly super-
vened, but likewise because of the unexpected consequences of this abscess.

This case was so tragic and surprising in its issue, as well as so widely
different from the general run of abscesses, and likewise presented so
many features worthy of special mention, that I requested Dr. G. to
furnish me with all the particulars, as far as possible, which would serve
to throw any light upon it, and with this request he promptly complied.
I herewith present his report of the case unabridged, lest by condensing
his account thereof, I should in any respect impair its value for future in-
vestigators, or weaken the lessons which it obviously inculcates.

Case I Private Albert J., aged 18 years, belonging to the Signal

Corps, was admitted into Stanton Hospital Alay 21, 1864, with gonor-
rhoea ; health otherwise apparently good ; he had neither sores nor swell-
ings on any part of his person.

May 22. Ordered magnesia sulphat. §j ; to be followed by the follow-
ing mixture : —

R. — Copaibas balsami,

Spt. aether, nitros.. aa 5j.
Liquoris potassas, ^ij.
Spt. lavendulas comp. ^ij.
Syrupi acacia?, jfvj. — M.
Sig. One tablespoonful three times per day ; wash frequently the parts in cold
water ; low diet, and rest in bed.

28^. Eenew the gonorrhoea mixture; also R. Zinci sulphat. gr. viij,
aquas §iv. M. S. Use this as an injection twice or three times per day.
The discharge has ceased, but medication is to be continued for better
security.

June 2. He has been ordered to do duty in the hospital wards, etc.
Considering the patient as cured, and not hearing anything further from
him, I lost sight of him from this time, and until I again found him in bed,
on June 22, complaining of a sore throat. Upon examination, I found
him free from gonorrhoea and with nothing to indicate a syphilitic taint.
He is perfectly free from sores and swellings of every kind, whether glan-
dular or otherwise, except a general inflamed condition of the fauces, ton-
sils, etc.; has cough, fever, and some difficulty of respiration; has had a
chill; complains of no pain. R. Quinias sulph. gr. vj, three times per
day; a Seidlitz powder every hour until it operates freely; apply ice to
throat ; and use for a gargle, R. Argent, nitrat. gr. viij, aquas 5 iij , syrupi
simplicis ^j, M., three times per day.

23c?. Continue the quinine and gargle, with ice to throat.

24th. General condition better ; chills have stopped ; throat, however,
continues sore ; cough, supposed to result from faucial irritation, still
troublesome. Continue quinine and the gargle, with ice to throat.

25th. Treatment to be continued unchanged.

2Qth. The left tonsil has become ulcerated. Excepting difficulty of de-
glutition, the patient appears to be a little better. He says he would eat
if he could swallow. Touched the tonsillar ulcers with caustic (argenti
nitras) ; ordered R. Potassas chlorat. 3^s, syrupi simplicis §j, aquas £iij.
M. Ft. gargarisma. To be used three or four times per day. Also,
magnesia sulphat. §ss, to be repeated if the bowels do not move in three

324

Lid ell, Abscesses of the Neck.

[Oct.

hours. His food to consist of animal broths or soups, milk, soft-boiled
eggs, custards, or any nourishing fluid food he will or can swallow.

July 1st. The patient's general condition is fair, with the exception of
sloughing about the tonsils and parts adjacent thereto. R. Potass, nitrat.
5ss ; ol. olivae, ^ij ; sacchari albi, 5j- M« Tere in mortario. Ordered the
ulcerated throat to be mopped with this mixture; also the chlorate of potassa
gargle, and the special diet to be continued.

6th. Patient decidedly better ; faucial ulcers nearly all healed, and he
has more appetite ; same treatment to be continued.

10th. Patient not so well ; he complains of heat and pain in the region
of the larynx, but the ulcers have healed over as far down as can be seen.
Ordered six dry cups to be put upon the upper part of his chest, to be
followed by a sinapism on his breast.

11th. Patient entirely relieved of his pain and difficulty of breathing by
the cups and mustard plaster, and he is doing well.

17th. He has some diarrhoea. R. Mistura contra diarrhoeam hospitalis.
Signa. Take one teaspoonful after each stool.

l$th. The diarrhoea is checked, and he feels tolerably well.

20th. Bowels again loose, but it does not amount to diarrhoea. Ordered
the diarrhoea mixture to be repeated.

21st. All medicine was stopped, and a full diet of whatever he could
swallow allowed.

23c?. Patient appears to be doing well generally, but he complains of a
feeling of soreness in the left side of his throat, which is also slightly
swollen. Ordered the painful and swollen part of his throat to be painted
with tincture of iodine, and as nourishing a diet as he could swallow to be
continued.

24th. Says he feels better; same treatment continued. But he died
suddenly in the afternoon of this day from asphyxia, caused by spasm of
the glottis.

Autopsy, twenty-four hours after death The ulceration of the fauces

had entirely healed. There was some extra redness of the larynx. But
just beneath the left sterno-cleido-mastoid muscle, in a line with the
thyroid cartilage, there wras an abscess about the size of an egg, filled with
a thick, yellow pus, which had burrowed down to about inches below
the omo-hyoid muscle.

There was also extensive hepatization of the lower lobe of left lung,
and middle lobe of right lung. The rest of the viscera, as far as examined,
were normal.

Comments Was the "sore throat " which attacked this young man,

some five or six weeks after he had become affected with gonorrhoea, in
reality a manifestation of constitutional or secondary syphilis, or not ?
This question, which obviously possesses very great practical importance,
however, cannot be answered with absolute certainty ; but, at the same
time, it appears highly probable that syphilis had no part in producing it,
firstly, because the clinical history shows a complete freedom from syphilitic
disease of the skin, lymphatic glands, eyes, bones, muscles, etc.; and,
secondly, had the affection of the throat been caused by constitutional
syphilis, recovery therefrom would not have followed so readily as it did,
under the plan of treatment detailed above.

1883.] Lidell, Abscesses of the Neck. 325

The autopsy showed that abscess underneath the left sterno-cleido-
mastoid muscle was developed in the connective tissue, and not from a
lymphatic gland. The autopsy also showed that the abscess, which had
appeared to be circumscribed when examined externally during life, was
in reality attended with an extensive burrowing of purulent matter in the
connective tissue adjoining it, especially in a downward direction, and " to
about one-and-a-half inches below the omo-hyoid muscle," as stated above.
And it is highly probable that the motor nerves of the laryngeal muscles,
L e., the recurrent laryngeal nerves, had been invaded or irritated by this
diffusion of purulent matter in the loose connective tissue, or the inflam-
matory process which attended it, in such a manner or to such a degree
as to suddenly cause a spasmodic closure of the glottis, and almost instant
death from asphyxia. It is also quite possible that I had myself unwit-
tingly aided to hasten the occurrence of this unhappy termination of the
case, by applying that very moderate degree of pressure to the swelling,
which it was necessary to use in order to determine the nature thereof,
for such an application of force would manifestly promote in a correspond-
ing degree the purulent diffusion just described. I make particular men-
tion of this point, because the calamitous result of this case clearly shows
that, whenever the surgeon has to examine cervical abscesses of a similar
character, he must always be prepared to lay them open and discharge
their contents on the spot, whether any symptoms of impending suffoca-
tion be already present or not.

To what should the so-called hepatization of the lower lobe of the left
lung and middle lobe of the right, which was noted at the autopsy, be
ascribed ? The clinical history of the patient does not warrant a belief
that it was due to an inflammatory process, i. e., to double pneumonia. It
is much more likely that this apparent solidification of the pulmonary
tissue resulted from the mode of death ; possibly it was caused by an
obstruction of the corresponding branches of the pulmonary artery with
blood-clots (emboli), detached from the right chambers of the heart by
violent struggles for breath during the last moments of life.

Functional disturbance of the recurrent laryngeal nerves to such an
extent as to seriously impair the action of the laryngeal muscles, and
arising from purely surgical affections, is by no means a novelty in sur-
gical literature, for it has likewise been observed in many analogous in-
stances. For example, the sagacious Hennen {Principles of Military
Surgery, pp. 286-289, Am. ed.) has reported, with his customary exact-
ness, the case of his friend, Lieutenant-Colonel A. C, a British officer,
who was wounded at Waterloo by a musket-ball, at short range, which
entered his neck about one inch above the level of his left clavicle, passed
backward through the sternal portion of the left sterno-cleido-mastoid
muscle, " and inward toward the thorax ; but no further trace of its route
could be discovered." It was followed by a great loss of blood, which

326

Lidell, Abscesses of the Neck.

[Oct.

ceased spontaneously. Very grave symptoms ensued, but it is unnecessary
to detail them here. On the fourth day, however, "a new symptom was
superadded ; his voice, which we had directed him not to employ except
on the most urgent occasions, was now lost altogether, and when addressed
he pointed constantly to the course of the recurrent nerves, so as to con-
vince us that an affection of them was the cause of this privation." In
this case these nerves were doubtless affected by the inflammatory swelling
with which holes when bored into the flesh by musket-balls are usually
attended; for, when this swelling subsided, his voice returned, and in the
end he appears to have entirely recovered from his wound.

But to return to the consideration of our own case : The autopsy showed
that the cervical abscess which had produced such dire consequences did
not arise from cervical adenitis, but from an inflammatory disorder of the
connective tissue, as already intimated above. Now to what course should
this disorder of the connective tissue, e., the abscess itself, be attributed?
It is quite possible that " hospitalism," or blood-poisoning of a peculiar
nature, caused by the prolonged breathing of an atmosphere which had
become infected in a peculiar manner, performed an important part in its
production; for, at this time, the wards of Stanton Hospital were strongly
infected with the corttagium of pyaemia, in consequence of a deplorable
mistake in the original construction of the hospital itself — a mistake which
consisted in constructing the inner walls of these wards of strong, thick,
buff-coloured paper, a substance highly absorbent and retentive of putre-
factive gases, instead of hard-finished plastering, which is comparatively
a non-absorbent substance (but I should here state that soon afterwards
this sad mistake was rectified, by tearing out the paper walls and putting
in others made of laths and plastering, as ought to have been done at the
outset). This view as to the influence which £< hospitalism" may possibly
have exerted in the production of this abscess, is favoured by the fact
•that, although it grew rapidly, it was not attended by the violent symp-
toms, e. g., the heat, the redness, the painfullness, and the excessive tender-
ness which characterize the formation of an acute or phlegmonous abscess
in this part, but rather by the local phenomena, both subjective and
objective, which often attend the formation of so-called secondary or me-
tastatic abscesses.

I have, however, once seen in private practice a deep-seated abscess of
the neck supervene during the stage of convalescence, from what appears
to have been cynanche tonsillaris.

Case II — A man, middle-aged, and of good constitution, with whom
I was well acquainted, came to my office, some years ago, stating that he
had recently had a " quinsy sore-throat," from which he was recovering,
and that his throat was now becoming inflamed again, but in a different
manner. He said the new attack had also caused much suffering. On
examination, I found an inflammatory swelling of considerable size, as
well as hard and brawny in feel, on the left front of his neck, extending

1883.]

Lid ell, Abscesses of the Neck.

327

from the base of the lower jaw downward to the middle of the neck, or
even lower ; the skin covering it was tense, hot, and reddened ; the swell-
ing itself was very painful and sore ; he could not bend his neck, and his
head was twisted to the opposite side ; he complained much of difficulty
in swallowing (dysphagia), but could not open his mouth wide enough to
allow me to look into his throat ; by inserting my finger, however, I ascer-
tained through the sense of touch that there was now no swelling of the
tonsils, and that no retro-pharyngeal abscess existed, nor was one form-
ing. Thus, it became clear that the external swelling was due to an acute
inflammation of the deep connective tissue of the neck, and that an acute
or phlegmonous abscess was probably being formed. I advised him to
use saline diluents, for he was very thirsty, to take as much nourishment
in the form of thin oat-meal gruel made with milk, and of beef-tea, as his
dysphagia would permit, and to diligently poultice the inflamed part with
flaxseed-meal cataplasms, frequently renewed. Three or four days after-
ward (for meanwhile I had visited him daily at his home), I satisfactorily
discerned deep-seated fluctuation in the swelling, and announced my in-
tention to lay it open at once, and thus give vent to the matter. But the
patient objected to my haste on the ground that the abscess was not yet
" ripe," inasmuch as no " pointing" had yet appeared. In reply I stated
that this abscess, owing to the peculiar structure of the neck, was much
more dangerous to life than most other abscesses, that before the purulent
matter it contained could spontaneously burst through the deep cervical
fascia so as to " point" externally, it would burrow more or less widely in
the loose connective tissue between the deep-seated organs of the neck,
and thus the abscess was very liable to cause sudden death by suffocation
at any moment, unless its contents should be discharged externally by in-
cising it. Then he suddenly remembered that his dysphagia was con-
stantly increasing, that his breathing, too, was already much obstructed,
and that he had been compelled to sit up through all the previous night
in order to avoid a sense of impending suffocation which appeared as
soon as he attempted to lie down. Thereupon, he quietly submitted.

Calling to mind the exact anatomical relation of the parts involved
in the proposed operation, while the patient remained seated in his easy
chair, but with his head firmly held by an assistant, I made an incision
about one inch in length along a line corresponding with the inner
border of the left sterno-cleido-mastoid muscle, over the summit of the
swelling (the centre of which incision was on a level with the upper
edge of the thyroid cartilage, and corresponded to the point where the
fluctuation was most distinctly perceived), with a scalpel through the
skin and platysma myoides; next, I cautiously raised and divided the
superficial fascia on a slim director ; then, recognizing the deep cervical
fascia, it too was raised in a like manner, and cautiously divided, to the
same extent as the cutaneous incision ; now, using only my fingers and
the rounded end of the director or grooved probe, I penetrated the under-
lying connective tissue with it, until purulent matter freely flowed in the
track made by it, thus showing that the abscess cavity was sufficiently
opened ; about an ounce of laudable pus was immediately discharged ;
there was considerable sanguinolent oozing from the lips of the wound,
but no vessel required ligation. The operation at once gave great relief.
That night the patient was enabled to lie comfortably in bed. The dys-
phagia rapidly disappeared. The abscess healed from the bottom without
difficulty under emollient cataplasms. His strength was rapidly restored

328 Lid ell, Abscesses of the Neck. [Oct.

by a generous diet combined with bitter and ferruginous tonics, but a
number of weeks elapsed before his countenance entirely lost the anaemic
appearance it had acquired from the malady.

In comparing this case with the preceding one, certain points of differ-
ence are to be noted, notwithstanding the general parallelism: (1) The
abscess was much more distinctly phlegmonous in the latter than in the
former instance; (2) No policy of delay was allowed to postpone the
operation for incising it, as soon as the presence of matter was satisfac-
torily discerned; and (3) this patient recovered. But, who can say what
the result would not have been had the evacuation of this man's abscess,
by incising it, been delayed from any cause for twenty-four, or even twelve
hours? It seemed to me, however, quite clear at the time that he was
exceedingly liable to perish suddenly of asphyxia within that period, at
any moment, if vent were not given to the matter without delay by using
the knife. This conviction arose in part from anatomical considerations,
e. g., the nearness of the abscess itself to the larynx, the dense structure
of the deep cervical fascia and the great difficulty or slowness with which
perforation of it is spontaneously effected by abscesses, together with the
loose structure of the subjacent connective tissue and the readiness with
which purulent matter may become diffused in it, especially under the
strong pressure exerted by the act of proliferation when the expansion of
the swelling is restrained externally by a strong membrane like the deep
fascia of the neck ; and likewise it arose in part from the presence of
laryngeal dyspnoea resulting from the abscess, which already caused the
patient much suffering, and now kept him entirely from lying down because
it instantly threatened him with suffocation wThenever he tried to assume
a recumbent posture. The indications were therefore very plain that this
highly dangerous abscess must immediately be evacuated ; and without
doubt, I think, had this abscess not been timely opened with the knife, I
should now have another fatal instance to record, instead of a gratifying
cure.

I have carefully detailed above the manner in which this abscess was
laid open, because a very eminent writer in surgery has dogmatically
declared concerning the opening of abscesses, without noting any excep-
tions whatever, as follows : " The surgeon should use a thin yet broad-
shouldered, sharp-cutting, double-edged knife or scalpel. And having
predetermined where to make his opening, and the probable thickness
of the parts to be divided, he should plunge the instrument rapidly and
boldly through the different tissues." (Holmes's System of Surgery, vol. i.
p. 122, 2d edition.) Further on he asserts : " There are some surgeons,
who, in opening an abscess, hold the knife as if they were dissecting, and
cut successively through skin, "subcutaneous tissue, fascia, etc. Such a
practice should not be tolerated ; it shows ignorance on the operator's
part, and aggravates the patient's sufferings to an unbounded degree."

1883.]

L i d e l l , Abscesses of the Neck.

329

[Ibid., p. 123.) Now, while I freely admit that these directions are sound
so far as the operation for opening abscesses in general is concerned — for
incising all those abscesses which are not in close proximity to great
bloodvessels and nerves, or deeply seated, or of doubtful diagnosis — I at
the same time firmly hold that it would be criminal recklessness for the
surgeon to plunge a bistoury " rapidly and boldly through the different
tissues" which cover the carotid artery, internal jugular vein, and pneu-
mogastric nerve, into a deep-seated abscess of the neck which had not yet
"pointed" or even approached the cutaneous surface, as must necessarily
have been done in the cases related above, if the abscesses had been opened
by a single thrust with a bistoury as practised for ordinary abscesses, and
as recommended by this writer. When, however, a cervical abscess has
already worked its way nearly to the cutaneous surface, or has become
" pointed," and is therefore but thinly covered at its summit, it should
always be opened with a single but a carefully guarded cut. But, when a
deep-seated abscess of the neck is to be laid freely open along the course
of the great bloodvessels of the neck, as in the examples presented above,
it must be exposed in a manner strictly analogous to that which is directed
by the canons of surgical art for uncovering the carotid sheath in the
operation for deligating that vessel. The sufferings of the patient in such
a case become a secondary consideration ; and the avoidance of them
therefore must not be allowed to endanger his safety. However, if time
and place permit, anaesthesia should be produced before operating.

Sudden death results from abscesses underneath the sterno-cleido-
mastoid muscle, or the continuance of life is greatly endangered thereby,
much oftener, perhaps, than is generally supposed. The examples pre-
sented above are by no means unique. Mr. Holmes Coote says he has
" known the disease prove fatal, by interfering with respiration," the
matter having become diffused. (Ibid., p. 125.) In 1847, a woman was
in St. Bartholomew's Hospital for a cervical abscess, deeply seated, and
raising the carotid vessels, which could be felt pulsating over it. There
was numbness of both arms, and partial paralysis of the lower extremities.
It was opened in order to obviate impending suffocation, and thick matter
to the amount of seven or eight ounces was discharged. This was followed
by immediate relief to all the symptoms ; and the functions of the limbs
slowly returned. (Ibid., pp. 126, 127.)

I will further illustrate this important subject, about which we know
far too little, by presenting a case taken from my note-book, wherein
death by suffocation suddenly resulted from an extensive abscess under-
neath the sterno-thyroid and thyro-hyoid muscles : —

Case III — Jacob M., aged 55, was admitted to the State Emi-
grants' Hospital, at Ward's Island, on the evening of February 15,
1850 (the writer was one of the assistant physicians thereof at the time).
The patient, when I examined him soon afterwards, presented the appear-

330

Lid ell, Abscesses of the Neck.

[Oct.

ance of a hard drinker, and was unable to give any account of himself in
consequence seemingly of intoxication. His neck was observed to be con-
siderably swollen ; his face also was swollen and red, especially about the
eyes, and presented the somewhat corrugated and desquamating look of
tegumentary erysipelas beginning to subside. On the following morning,
at an early hour, I saw him dying of asphyxia, his countenance being
blue, lips livid, etc.; but his general condition was so bad, and the diag-
nosis so uncertain, that no operative procedure was thought to be war-
ranted.

Autopsy, twenty-eight hours after death. — Cadaver not emaciated ;
rigor mortis well marked ; the neck remains considerably swollen ; the
left side of face also still swollen. An extensive abscess was found im-
mediately beneath the thyro-hyoid and sterno-thyroid muscles ; it was
bounded posteriorly by the thyroid cartilage and thyroid body; the con-
nective tissue under these muscles had been largely consumed in its
formation ; it likewise extended downward under or behind the sterno-
thyroid muscle nearly to the origin thereof, i. e., to within an inch of the
sternum ; more than one-half of the external surface of the thyroid car-
tilage was laid bare by the abscess, but it was not ero'ded. The pharynx
and fauces were inflamed ; they also exhibited four or five follicular ab-
scesses having the size of pigeon-shot. There was an erosion or ulcer on
each lateral edge of the epiglottis at its base. The mucous membrane of
the larynx and trachea was inflamed, but it exhibited no purulent matter
or false membrane. The submaxillary glands on both sides were en-
larged ; those on the left contained a few points of infiltrated pus. Both
parotid glands were likewise enlarged ; the right one was also softened
and extensively infiltrated with pus.

Right lung extensively fastened to chest by tolerably firm adhesions ;
inferior and middle lobes thereof in the third stage of pneumonia ; supe-
rior lobe oedematous, and its apex contains some tubercles which have
undergone a calcareous transformation. Left lung congested ; its apex
adherent, and contains a considerable quantity of tuberculous matter
which has also become calcified. Bronchial glands enlarged and calcified.
The bronchi contain considerable muco-purulent matter. Heart large
and flabby ; its right chambers are distended with blood, while its left
are nearly empty. Liver larger by one-half than natural, and congested.
Spleen three times larger than normal, and congested. Kidneys con-
gested. Stomach actively congested ; its mucous membrane thickened
(apparently by a chronic process), and softened. Intestines in good con-
dition. The congestion above mentioned was mostly venous, and there-
fore quite passive ; it arose from the mode of death.

This man was already moribund when he came to hospital ; and the
autopsy shows that no chance then remained for the medical or surgical
art to rescue him from death. Although his previous history is unknown,
the objective phenomena observed after admission and the revelations
made by the autopsy are instructive. Life was suddenly terminated by
asphyxia ; and the external evidences of this accident, the cyanotic hue
of the countenance, etc., were strongly marked. But the internal evi-
dences brought to light by the autopsy were not less striking. They were
engorgement of the pulmonary artery and its branches, distension of the
right cavities of the heart, while the left were nearly empty, and general

1883.]

Lidell, Abscesses of the Neck.

331

venous congestion. Moreover, the cervical abscess which caused the mis-
chief was found to be still imprisoned within the deep cervical fascia.
The abscess itself was shown to have resulted from an inflammation of
the deep connective tissue which was widely destroyed thereby ; the puru-
lent matter it contained had shown no disposition to "point ;" on the con-
trary, this matter, having cleanly dissected off the exterior of the larynx
to a large extent, had followed the sterno-thyroid muscle downward almost
to its origin, instead of making its way towards the cutaneous surface. In
the conduct of this abscess Nature manifested no conservatism — no incli-
nation to effect a spontaneous cure. Here we clearly perceive the chief
reason why it is the surgeon's duty to at once lay open with the knife all
deep-seated abscesses of the neck, namely, they do not tend to spontane-
ously get well, but, on the contrary, to destroy life. Finally, the autopsy
of this man shows that, even had the cervical abscess been discerned
and opened as soon as he came to the hospital, his life would not have
been saved thereby, because there also existed an extensive purulent infil-
tration of the right parotid, and left submaxillary glands, and of the infe-
rior and middle lobes of the right lung ; and, no doubt, the symptoms of
septicaemia, too, were present during life.

I can still .further illustrate this comparatively obscure subject in a
useful manner by presenting another example taken also from my note-
book : —

Case IV Margaret C, aged 40, born in Ireland, was admitted to

the State Emigrants' Hospital, at Ward's Island, on October 18, 1849,
where I was then one of the assistant physicians. She said her illness
was of two weeks' standing. Her cheeks, neck, and throat were very
much swollen at the time of admission; tongue swollen; the loose con-
nective tissue about the root of tongue much swelled also, but most so on
the right side ; voice impaired ; deglutition difficult; respiration fair. A
view of her fauces could not be obtained from inability to open her mouth
wide enough to allow it. There was but little redness and heat of the
skin which covered the swollen throat, neck, and cheeks. Subsequently,
the swelling of the tongue, and of the connective tissue about its root,
gradually subsided ; but difficulty of breathing (dyspnoea) came on in the
evening, and increased in severity every evening until the 26th, eight
days after admission, when she expired, in consequence of laryngeal
asphyxia (oedema glottidis). On the 24th, two days before death, she
began to expectorate an unhealthy pus, like that produced by erysipelas.
On the day she died, this expectoration was very free, and the swelling of
her neck diminished in proportion.

Autopsy, twenty hours after death Embonpoint preserved ; some pale

frothy fluid between the lips of the cadaver was noted. The deep con-
nective tissue between the muscles of the throat, or anterior half of the
neck, was found completely disorganized by an inflammatory process, so
that pus and sloughs were present throughout, and an immense deep-
seated abscess of the neck was thereby constituted. Pharyngitis also was
present; it was most marked on the right side of the organ, where an
aperture was found in its walls which communicated with the cavity of

332

Li dell, Abscesses of the Neck.

[Oct.

the abscess, and through which the unhealthy pus expectorated during
the last two days of life had obviously been discharged. Here the abscess
evidently had burst into the pharynx. The larynx was inflamed ; and an
obstructive oedema of the glottis was found. Below the rima glottidis, the
larynx and the upper part of the trachea were filled with colourless frothy
serum. But little fibrinous exudation, and no ulcerations were found on
the mucous membrane lining the larynx. The epiglottis was bright red
in colour. The trachea was also inflamed. There were pleuritic adhe-
sions, both interlobar and parietal, of a rather recent date, on the left side
of the chest. The lungs were much congested, but otherwise normal.
Liver enlarged and congested. Uterus gravid ; it contained a foetus in
the fourth month of its development. There was venous congestion
throughout the body, obviously caused by the mode in which death had
been produced.

The mechanical cause of asphyxia, in this case, was oedema of the
glottis. It resulted indirectly from the sloughing and suppurative inflam-
mation (or abscess) of the deep cervical connective tissue, especially of
the portion which surrounds the larynx, in consequence of the inflam-
matory process being propagated therefrom, through contiguity, to that
organ. It may be well to remember, in this connection, that the upper
part of the trachea, the epiglottis, and the pharynx, had also become
inflamed in the same way. Moreover, the oedema glpttidis, which
killed this patient, ensued, notwithstanding the fact that the abscess itself
had burst two days before and spontaneously discharged most of its
contents.

The suppuration in this instance was an unhealthy one, as was evi-
denced by the matter discharged during life, and by the contents of
the abscess revealed by necroscopy. Thus, it is shown that the con-
nective tissue inflammation which produced it was an unhealthy inflam-
mation, and one which naturally tended to become diffused rather than to
remain circumscribed. Here we should note particularly that the patient
was a poor, ill-fed, Irish peasant woman, who had but recently come
to America, and that her depraved general condition had probably
determined the character of the local inflammation. Now, experience
has abundantly shown that there is but a very small chance to save such
examples of a diffuse and rapidly destructive inflammation of the con-
nective tissue between the deep muscles, especially of the neck, unless
there be employed from the outset a strongly supporting plan of treat-
ment, e. g., tincture of the ferric chloride and quinine with alcoholics, in
full doses, and a diet easily digestible, and as highly nutritious as pos-
sible ; together with deep incisions made as freely and as early as possible,
in such a way as to liberate completely the sloughing tissue and the puru-
lent matter as soon as they exist. From the want of such remedial
measures seasonably applied, this patient, when she entered the hospital
two weeks after her malady began, was in reality too far gone to be
saved by any plan of treatment. But why was there no attempt made to

1883.] Lid ell, Abscesses of the Neck. 333

relieve the laryngeal obstruction — the oedema glottidis — by performing a
surgical operation ? It was because the larynx and upper part of the
trachea were so completely surrounded by the abscess - cavity above
mentioned, in front as well as on both sides, that the operation of laryn-
gotomy or tracheotomy could not be performed without great difficulty,
and even then did not offer any reasonable hope of success, because, if the
windpipe were opened by an incision, the matter from the huge abscess
would suffocate the patient by flowing downward into that tube. More-
over, the closure of her mouth in consequence of tumefaction, etc., utterly
precluded any operation from that direction.

This example, then, affords another melancholy illustration of what is
certain to ensue in cases of deep cervical abscess, whenever the requisite
plan of treatment is not seasonably employed. It also shows, like the
preceding case, that such abscesses, when allowed to run their own course,
do not exhibit any tendency to a spontaneous cure ; but, on the contrary,
they always tend to destroy life.

To complete the consideration of this branch of the subject, it is, per-
haps, well to briefly state that deeply seated abscesses of the neck may
burrow widely in other directions, and thus result in death. For instance,
a man aged 31 entered St. Bartholomew's Hospital with pneumothorax
on the right side and general emphysema. He had, however, suffered for
some time before these disorders appeared, from pain in his throat and
difficulty in swallowing. The autopsy revealed an abscess in the deep
connective tissue of his neck, which had burrowed extensively therein,
and had likewise burst in two directions, namely, into the upper part of
the oesophagus on one side, and into the right pleural cavity on the other.
(Ibid., p. 125.) Mr. Callender has examined post-mortem two cases in
which there was a deep-seated, burrowing abscess of the neck; in one of
them, the pus made its way into the anterior mediastinum ; in the other,
it surrounded the trachea and extended downward to the roots of the lungs.

But enough has been said to clearly show that the earlier all deep-
seated abscesses of the neck are laid open and evacuated the better for
both patient and surgeon. And wheresoever, in such cases, the abscess
may form, the plan of treatment is always the same. As soon as fluctua-
tion is discerned, the surgeon must proceed without delay to discharge
the matter by making a suitable incision, in order that the abscess may
not spread downward into the thoracic cavity, nor burst into any part
essential to life, nor suddenly cause death by asphyxia.
• Moreover, every medical man should impress indelibly upon his memory
the fact (which has been clearly shown above), that deep-seated abscesses
of the throat or neck do not, as a rule, tend to spontaneously get well ;
that if they be let alone, or be expectantly or inadequately treated in
any other wTay, they naturally act destructively by burrowing or spread-
ing, etc., and thus kill with great certainty; that there are but few if any

334

Lid ell, Abscesses of the Neck.

[Oct.

exceptions to this rule ; and, finally, that in all cervical abscesses which
are deeply seated, as well as in all cerebral abscesses, the practitioner has
no right ever, for a single moment, to expect a successful result unless the
matter be promptly discharged by making a suitable incision. The
corollary to this proposition is obvious : Should the practitioner not feel
himself quite competent to undertake such an operation while the matter
is still far below the cutaneous surface and close to the great bloodvessels
of the neck, or should he have any doubts about his own ability to discern
fluctuation, in such cases, while it is still deeply seated, by the tactile
sense alone, he must get competent assistance without delay ; for, by
waiting under such circumstances, he will always diminish considerably,
and sometimes destroy utterly, his patient's chance of recovery.

Besides an extremely early evacuation by means of a suitable incision,
the abscesses described above usually demand the employment of Chas-
saignac's drainage-tubes and antiseptic dressings ; this point in their
treatment I here mention once for all.

Brief mention, too, must be made in this place of retro-pharyngeal
abscesses, inasmuch as they are always difficult to treat, and are very
liable to cause sudden death ; and because, from their kinship thereto,
their description naturally follows that of deep-seated cervical abscesses in
general. The following examples will serve to illustrate their symptom-
atology, as well as the chief dangers which attend them.

Case V Dr. Levertin (Hygiea, Bd. xxi. p. 692) reports the case of

a peasant, aged 46, who, after recovery from typhus and gastric fever,
was attacked with dysphagia, on October 13th. Nothing wrong was found
in the neck. Next day, the dysphagia was so great that not even a drop
of water could be swallowed ; fits of suffocation also occurred.

11th. A swelling was discovered in the pharynx, and tracheotomy was
performed by Professor Sautesson. This was followed by some improve-
ment in breathing and swallowing ; but death took place on the 19th.

Autopsy The oesophagus, etc., having been laid open from behind,

two yellow points were found in its anterior wall, over the arytenoid
cartilages. A probe, having been passed into the point on the right side,
slipped into the cavity of an abscess as large as a hazel-nut. The larynx
was highly inflamed ; but the abscess-cavity did not communicate with it.
{New Sydenham Soc. Year-Book for 1861, pp. 248, 249.)

The symptoms which resulted from the abscess in this instance were
(a) dysphagia, which came on suddenly and increased so rapidly that on
the day following the attack nothing whatever could be swallowed ; and
(6) a swelling containing purulent matter which projected into the
pharynx. Fits of suffocation also supervened as soon as the inflammatory
process had spread by contiguity to the larynx ; and, notwithstanding that
the operation of tracheotomy appears to have been seasonably performed,
this secondary laryngitis caused death by asphyxia. The only operation
which might have saved this patient was the puncturing of the abscess

1883.]

L i d e l l , -Abscesses of the Neck.

335

and the discharge of its contents, at an 'early period in its growth, and
before the inflammation had yet spread from the abscess to the larynx.

Case VI A powerful young man, aged 15 ( Wiirtemb. Corresp. Blatt.

xiv. 1858), experienced pain and swelling at the back of his throat, with
inability to turn his head, and to open his mouth. There was a painful
swelling found in the right parotid region ; tonsils normal ; no fever.
During the first fourteen days the symptoms were somewhat severe, some-
times easier. On the sixteenth clay, hemorrhage from the mouth and
nose occurred. On the eighteenth day, the swelling at the back of his
throat opened spontaneously, and discharged a quantity of bloody, wine-
lees-coloured pus. But the swelling was still visible behind the soft palate.
After some hours, about a pint of bright-red blood suddenly issued from
his mouth and nose ; its source was never discovered. Four days later,
another hemorrhage occurred, but from the mouth alone. On the follow-
ing clay, a hemorrhage still more severe took place from his nostrils. The
external swelling became larger and more painful. In the fourth week,
the retro-pharyngeal abscess burst a second time, under precisely similar
circumstances, and gave ease to the patient, with cessation of cough, etc.
The internal swelling pushed the uvula forward ; but, as this swelling
abated, the external swelling was correspondingly diminished. The pa-
tient, however, died suddenly one night from hemorrhage, which had
recurred in a severe form after an interval of fourteen days.

Autopsy A carious piece of bone was found on the anterior surface of

the body of the atlas. There was an abscess cavity in the connective
tissue between the right tonsil and parotid gland, about the branches of
the carotid artery, having the size of a hen's egg. It was filled with blood-
clot ; but the immediate source of the hemorrhage was still uncertain.
Two small openings through the wall of the abscess into the mouth were
found. {Holmes's System of Surgery, vol. i. pp. 133, 134, 2d ed.)

This abscess arose from caries of the body of the first cervical vertebra.
The symptoms which it presented were pain, soreness, and swelling at the
back part of the throat, with dysphagia and inability to turn the head.
But the diagnostic sign was the swelling caused by the abscess itself, which
was situated behind the curtain of the palate and on the posterior wall of
the fauces, and was plainly perceivable by the senses of both touch and
sight. To these symptoms, some phenomena were superadded which may
with propriety be termed accidental, because they resulted from a casual
extension of the abscess-cavity toward the right parotid gland. The
diagnosis in this instance was easily made ; as, indeed, it generally is in
the examples of this affection where the buccal and faucial cavities are
accurately examined by sight and touch, or even by the educated touch
alone, when the patient's mouth cannot be opened widely enough to obtain
a view. But this patient suddenly expired from hemorrhage, caused by
the erosion of some sufficiently important bloodvessel in the abscess-cavity.
On this sort of hemorrhage, however, it will presently be necessary to
speak again.

Some additional points in the history of this highly dangerous disorder

336

Lid ell, Abscesses of the Neck.

[Oct.

can best be illustrated by briefly mentioning an example which was treated
by the writer with success, some years ago, in Bellevue Hospital.

Case VII The patient was an Irish woman, aged about 30, rather

lean and pale, but free from constitutional taints, who said she had been
ill but a few days with sore throat and dysphagia. Her voice was much
affected, her mouth partly open, and her breath on issuing from it very
offensive or stinking. She complained of pain and soreness in the fauces,
and that they were greatly aggravated by all attempts to swallow (i. e.,
there was much dysphagia). Her neck was stiff, and she was unable to
rotate her head. Externally, there was a tender and painful swelling
found in each parotid region. Her mouth would not open wide enough to
afford a view of her fauces. On inserting the right index finger, however,
I discovered a rather soft swelling which projected into the pharynx from
behind to a considerable distance, apparently almost to the soft palate,
and that both tonsils were normal. Believing that I now had to deal with
a retro-pharyngeal abscess, I determined to lay it open at once; and,
taking in my right hand a long straight, but narrow bistoury or finger-knife,
whose cutting-edge was covered with adhesive plaster, excepting about
one-third of an inch at its point, while she Avas sitting in a chair with her
head firmly held by an assistant against his breast, and her teeth were
separated by a cork, so that she could not bite, being guided into her
mouth by the index finger of my left hand with which her tongue was
simultaneously depressed, I passed the instrument directly backward into
the centre of the swelling, and incised it vertically as freely as possible, in
the middle line. A considerable quantity of pus mixed with blood was im-
mediately discharged, which afforded great relief. It was directed that her
throat should frequently be swabbed with liquor sodse chlorinatae diluted
with water (part 1 to parts 10), that tincture of the ferric chloride with
quinia should be administered in full doses, that milk punch, too, should
be freely given, and that a nourishing diet, consisting of chicken-broth,
beef-tea, eggs, and anything she could swallow, should be allowed. The
abscess became refilled twice ; but it was promptly re-opened each time,
in the manner described above. In the end, the patient completely re-
covered. My unhappy experience with the emigrant cases related above,
no doubt, had prepared me to treat this case with much greater satisfaction.

To recapitulate some of the chief points in the history of this highly
dangerous disorder : (1) It may result from disease of the cervical verte-
brae, on the one hand, and from connective tissue inflammation, on the
other. (2) It may cause sudden death by inducing suffocation, by lead-
ing to starvation, and by producing a great hemorrhage. (3) In order to
treat this grave disorder with success, it is necessary that the diagnosis
should be made at an early date, that the pus should be promptly dis-
charged by making a suitable puncture (the earlier the better), that the
matter should be promptly let out again and again should the abscess
refill, and that chlorinated gargles or washes, with a strongly supporting
plan of treatment, should be employed.

Furthermore, various abscesses of the neck may cause sudden death by
eroding the cervical bloodvessels, arfd thus suddenly producing a great
hemorrhage. A striking example of this accident has just been presented.

1883.]

Lidell, Abscesses of the Neck.

337

It seems, too, that our predecessors were familiar with this occurrence in
other parts of the body, as well as in the neck ; for John Pearson {Prin-
ciples of Surgery ; pp. 99, 100, London, 1788) observes, in a general way,
as follows : " Although the larger arteries have been known to be sur-
rounded with purulent matter for a considerable time without suffering
any injury, yet this is not universally the case ; there have occurred many
instances where erosion has taken place, and the person has been sud-
denly destroyed with hemorrhage." It is probable that dangerous hemor-
rhage results from this cause in the cervical region much oftener than
many suppose. The late Dr. George McClellan, of Philadelphia, has
recorded two instances, brief abstracts of which should here be given : —

Case VIII Mr. Slack, prothonotary at Mount Holly, N. J., had epi-
demic influenza, which terminated in a critical abscess of a submaxillary
gland. This abscess, on being lanced, discharged an ichorous sanies. A
few days afterward, a violent hemorrhage broke out, and continued in spite
of pressure and cold applications until complete syncope. As often as he
reacted, from day to day, the hemorrhage returned, and produced a renewed
fainting. After several repetitions of this process, an alarming prostration
supervened, and Dr. McClellan was called in consultation. He says : " As
the hemorrhage plainly proceeded from some artery in the abscess-cavity,
I dilated the orifice through the purple and undermined integument and
fascia of the throat and jaw ; and, on sponging out the soft coagula, I
found that the facial artery had been ulcerated into, just as it passed over
the base of the jaw-bone, and that its loose end hung clown and pulsated
into the cavity of the abscess. I held it between a thumb and finger,
applied the ligature ; but it proved to be so soft and rotten, that the thread
cut through it instantly. I repeated the same attempt twice, nearer the
origin of the artery ; the last time even after dissecting it out a little from
above the submaxillary gland, and underneath the jaw, and the same
result followed. The cellular sheath appeared to have been dissolved or
softened by the morbid inflammation and unhealthy suppuration which
had produced the abscess. As the hemorrhage was greatly increased by
these attempts, I seized a spike of iron from the kitchen-wall, and, after
heating it red-hot in the stove, I applied its point to the bleeding orifice.
The hemorrhage then ceased permanently ; and, on applying creasote
washes, and ordering tonics and improved diet, we shortly had the pleasure
of his perfect recovery." (Principles and Practice of Surgery, p. 200,
Philadelphia, 1848.)

Case IX The second case occurred in the person of Mr. Ashman, of

Ohio, after a great deal of inflammation and mechanical disturbance about
the throat, in consequence of severe operations for securing the external
carotid artery, and afterwards the internal carotid, in connection with the
extirpation of a scirrhous parotid gland. After the wounds of operation
had nearly cicatrized, and the patient had recovered strength enough to
go out, the lower angle of the old wound broke open afresh, and discharged
a violent hemorrhage. This repeatedly occurred, and finally made a large
cavity beside the larynx and trachea. On laying it freely open, the su-
perior thyroid artery was discovered at the bottom of the wound, exposed
for fully one inch, with a rent or fissure in its tube, from which the blood
was welling out. On attempting to ligature it, the thread cut through its
tunics at every trial exactly as in the preceding case. Dr. McClellan
No. CLXXIL— Oct. 1883. 22

338

Lidell, Abscesses of the Neck.

[Oct.

says : "I then took a pointed stick of pure lunar caustic, and seared the
two ends thoroughly, and afterwards pressed a dossil of lint wet with pure
creasote upon them. This commanded the hemorrhage effectually, and
the patient recovered by a return of healthy suppuration and granulation,
under the use of tonics." (Ibid., pp. 200, 201.)

This sagacious observer also remarks, in substance, that the various
instances, which have been reported, of arteries, and of even veins, having
been opened by ulceration or erosion into the cavities of neighbouring
abscesses, must be classed in the same category. The softening of their
coats by a peculiar species of inflammatory ramollissement has led the
way to the hemorrhage. Such cases, instead of resulting from a hemor-
rhagic diathesis or a constitutional predisposition, are plainly derivable
from the depraved character of the inflammation which has preceded
them. In further support of this view he declares : " I have known of
several cases of sudden death from hemorrhage from abscesses and irrita-
ble sinuous ulcers in the throat, which resulted from malignant scarlatina
in children, all of which undoubtedly must have occurred in the same
way." {Ibid., p. 201.)

But the abscesses which result from ordinary tonsillitis (or c}rnanche
tonsillaris) have been attended by fatal or very dangerous hemorrhages,
in consequence of the adjoining bloodvessels being eroded, with peculiar
frequency. Many instances thereof have been recorded. Dr. Ehrmann
reports (Centralblatt fur Chir., No. 34, 1879) the following instructive
case : —

Case X. — An Italian, a young man, entered hospital for angina tonsil-
laris. On the third day the abscess spontaneously burst open, and imme-
diately half a litre of bright-red blood poured from the mouth. Three hours
later the hemorrhage recurred, but in less quantity. No pulsation in the
tonsillary swelling was perceptible. A third hemorrhage, more severe
than the others united, led to the tying of the common carotid artery with
two threads, between which it was severed. The hemorrhage ceased per-
manently. No cerebral symptoms ensued, excepting aphonia, which dis-
appeared in four days. In six weeks he was discharged cured. (New
York Medical Journal, October, 1879.)

It is not improbable that in some, perhaps in most, of the cases in which
the puncturing of a tonsillary abscess is said to have been attended with
a fatal or a very dangerous hemorrhage, the loss of blood has in reality
been caused by an erosion of the tunics of the bleeding vessel effected
by the abscess itself, and not by any wound of these tunics inflicted by the
surgeon's knife. Such .occurrences have been noted now and then ever
since the time of Portal, who mentions a case in which, while opening a
tonsillary abscess with a pharyngotome, " a dexterous surgeon of Mont-
pellier had the misfortune to open a large artery, and see the patient
perish of a hemorrhage so severe that nothing could arrest it." (Cours
d' Anatomic Medicale, t. v. p. 509.)

1883.]

Lid ell, Abscesses of the Neck.

339

It seems to the writer more probable, however, that the arterial tube even
in this case was spontaneously opened by the disease, than that it was acci-
dentally punctured by a dexterous surgeon ; the arterial tunics well may
have become so much weakened by the morbid process that they yielded
to the blood-pressure as soon as the external support afforded by the con-
tents of the abscess was withdrawn by puncturing it, and then the bleed-
ing would have occurred just the same if the abscess had burst sponta-
neously, instead of being opened by the surgeon. Moreover, in Dr.
Ehrmann's case just related, the hemorrhage with which the spontaneous
opening of the abscess was immediately attended would have been erro-
neously attributed to the operation of puncture, if that operation had
been performed. The same criticisms are applicable to the other cases
belonging to this category. For example : " Tyrrell was accustomed to
mention, in his surgical lectures, a case to which he was fetched by a prac-
titioner, who, having punctured an abscess in the tonsil-gland, the wound
was immediately followed by severe bleeding, and the patient was dead
before he could reach the house." Again : Sir Benjamin Brodie was
" cognizant of two cases in which death ensued after the puncture of ton-
sillar abscess." (South's Notes to Chelius' Surgery, vol. i. p. 162, Am. ed.)
But it does not appear that in either of these cases the arterial lesion was
accurately determined by a post-mortem examination ; and, in the absence
of such information, it seems more probable that the hemorrhage in each
instance was caused by disease of the arterial tunics, as it was in Dr.
Ehrmann's case, than by wounds of these tunics inflicted by surgeons.
I have dwelt upon this point somewhat, because it is of much practical
importance that such hemorrhages should always be attributed to the right
cause.

It is also of importance to know that in cases of spontaneous hemor-
rhage from tonsillary abscess, the erosive action or ulceration may have
opened some branch of the external carotid artery, as well as the trunk of
the internal carotid ; and that the occurrence of such hemorrhages is not
restricted to the lesion of a single artery.

On taking a comprehensive view of the subject, it would seem that
abscesses in the neck are more frequently attended with hemorrhages due
to the opening of important bloodvessels by ulceration or erosion, and by
ramollissement consequent upon the disorders themselves, than abscesses
in the other surgical regions. The superior liability of cervical abscesses
to the spontaneous occurrence of dangerous hemorrhages arises in part
from the greater number and importance of the cervical bloodvessels ;
but more particularly, I think, from the inanition and exhaustion, or low
state of the constitutional powers, and consequent feebleness of the repara-
tive forces, which rapidly result from most of the deep abscesses of the
neck, or rather from the inability to swallow enough food to support life,
and from the powerlessness to get any refreshing sleep, or even repose,

340

Lid ell, Abscesses of the Neck.

[Oct.

with which these abscesses are oftentimes attended. The septic or tox-
emic influence of the fetid secretions and exudations which present
themselves in the oral and faucial cavities in many instances, also aids
materially to still further depress the patient, and weaken the reparative
processes of his system.

Finally, how should the hemorrhages which spring from these cervical
abscesses be treated ? The chief points in the therapeusis, both chirurgi-
cal and medical, have already been mentioned while presenting the several
examples of this accident. To briefly recapitulate them : The abscess-
cavity in such cases always should be freely laid open, the coagula turned
out, the bleeding point or source of the hemorrhage brought distinctly into
view, and the delinquent vessel itself should be ligatured on each side of
the aperture in its walls. But should the ligatures cut through, i. e.,
should the vessel's tunics prove to be too soft or too weak to hold the
threads, the actual cautery must be applied to the bleeding point, as was
practised by McClellan under such circumstances, as stated above. And
especially is the practitioner to be warned against the use of liquor ferri
persulphat. or perchlorid. as styptics in such cases ; because, if he employ
these acid ferric salts, he will not unfrequently fail to suppress the bleeding
permanently, on the one hand, while he will, at the same time, always do
considerable harm by causing a hard and quite insoluble coagulum to be
formed by them which will greatly interfere with the subsequent applica-
tion of ligatures or of the actual cautery in cases of failure to control the
hemorrhage ; and, even in cases of success, will greatly retard the cure,
from irritation and difficulty of removal.

An antiseptic plan of after-treatment, with thorough drainage of the
abscess-cavity by means of Chassaignac's tubes, is generally of much
value in cases of hemorrhage from cervical abscesses ; and it is of interest
to note in this connection that the sagacious McClellan had already found,
long prior to his sudden death in 1847, the great value of antiseptic dress-
ings in such cases, and he makes particular mention of " creasote washes,"
i. e., lotions containing impure carbolic and cresylic acids. To this plan
of after-treatment, the ferruginous and bitter tonics, e. g.y quinine and iron,
in full doses, should be added, together with milk-punch, wine, or porter,
and a very nourishing diet.

But what should be done in cases where the abscess-cavity cannot be
laid open, so as to expose the bleeding vessel to view, and allow it to be
secured with ligatures, or restrained from bleeding by applying the actual
cautery? In such cases, the primitive carotid artery should be firmly
compressed against the cervical vertebrae by the surgeon's thumb or fin-
gers applied on the anterior part of the corresponding side of the neck,
between the larynx or trachea and the inner border of the sterno-cleido-
mastoid muscle, with force enough to press the artery backward and inward
against these vertebrae, and flatten it thereon. This pressure should be

1883.]

M o r i s o n , The Prurigo Papule.

341

exerted continuously and sufficiently, as well as in the right direction to
embrace the artery between it and the bone ; also long enough for the
apertures to become securely plugged with coagula, if possible. Should
this procedure fail, it will be advisable, especially in cases where the bleed-
ing proceeds from tonsillary abscesses, to ligature at once the primitive
carotid artery. This vessel is to be selected for deligation in such cases
because it cannot be determined during life whether the hemorrhage from
a tonsillary abscess has its source in a branch of the external carotid artery
or in the trunk of the internal carotid artery, as already stated above.
And by the timely performance of this operation, in such cases, the sur-
geon may often be gratified, as, indeed, Dr. Ehrmann, mentioned above,
was gratified in seeing the hemorrhage permanently suppressed and his
patient saved.

What plan of treatment might possibly have saved the case of retro-
pharyngeal abscess, mentioned above (Case VI.), in which death from
hemorrhage suddenly occurred ? It should, in the first place, be observed
that the collection of matter was what our predecessors were wont to term
a congestive, instead of a phlegmonous abscess, i. e., the purulent matter
having been formed elsewhere, in consequence of caries of the first vertebra,
had settled downward behind the pharynx, etc., and therefore this matter
was not the product of connective-tissue inflammation behind the pharynx.
It may well be that, had this purulent depot been fully emptied by an
early-made incision, and subsequently kept empty in the same way, had
the patient's throat been cleansed at short intervals with chlorinated washes
(e. g., liquor sodas chlorinat., part 1, to aqua, parts 8 or 10), and had his
strength been sustained by administering iron and quinia, with alcoholics,
and all nutritious kinds of food which could have been swallowed, the sys-
temic deterioration and the hemorrhage resulting therefrom would have
been prevented.

Article II.

A CONTIBUTION TO THE GENERAL KNOWLEDGE CONCERNING THE PRURIGO

Papule. By Robert B. Morison, M.D., of Baltimore.

Although there has been much written about, and many descriptions
made of, the histology of the prurigo papule, the opinions of authors have
not always agreed ; and it was with the idea of settling as far as possible the
disputed points and differences, that I undertook the following investiga-
tions in Prof. Chiari's pathological institute at Prague, on material kindly
furnished by Prof. Pick, Avhich was taken intra vitam at various stages
of the disease under the latter's personal supervision.

342

Mori son, The Prurigo Papule.

[Oct.

Earlier authors examined the skin after death, or were satisfied with a
few specimens taken intra vitam, but the material furnished me by Prof.
Pick has been such that no stage of the disease has been wanting. No
other, then, has had the chance thus offered for a careful and thorough
investigation into the changes occurring in prurigo.

Before the time of Hebra, prurigo and pruritus were synonymous terms.
Willan1 divided prurigo into four classes : P. mitis, P. formicans, P.
senilis, P. sine papulis. His idea was that the itching represented the
chief symptom, and that the absence or presence of papules did not change
the character of the disease. Macroscopically, he describes them as soft
and smooth, rather larger and less pointed than those of lichen, and as
seldom red or inflamed, excepting when rubbed or scratched. They are
covered with crusts formed from the thickening of a watery fluid mixed
with blood contained within them, which is seen when the tops of the
papules are removed in any way. The author looks upon the disease as a
neurosis.

Bateman2 follows Willan in his description of the papule, as does also
Plumbe,3 the latter remarking that they are in no way necessarily present
in the disease known as prurigo, and that in fact, in most cases coming
under the notice of a physician, itching is the only symptom.

Alibert,4 also recognizing no difference between pruritus and prurigo,
says, however, that this disease, which he calls " psoride papuleuse," con-
sists of a characteristic eruption of papules which in form and colour
resemble the skin.

Cazenave5 describes them more minutely, and says that they are some-
times small, slightly raised above the skin, perceptible to the touch, and
accompanied with severe itching ; at other times they are larger, more
elevated, and accompanied with itching, which is unbearable. They
never touch each other, and have generally the same colour as the skin,
when they have not been torn by the nails. When present in great
quantities, and when their tops are scratched off, a drop of blood escapes
which coagulates and forms a characteristic crust. In many cases this
crust falls off, leaving behind a somewhat prominent point. Sometimes
the papule disappears entirely with it. Those papules which have not
been torn off, either disperse themselves, or disappear by the formation
of fine scales which afterward drop off. Where the disease has lasted
for a long time, they are hard, very large and prominent. The eruption
is accompanied with a noticeable thickening of the skin.

The same author6 considers prurigo an inflammation of the nerve end-

1 On Cutaneous Diseases, 1S08.

2 Practical Treatise on Skin Diseases, 1835.

3 On Diseases of the Skin, 1827.

4 Descriptions des Maladies de la Peau, 1825.

5 Abrege pratique des Maladies de la Peau, etc., 1838.

6 Gaz. des Hop. 1847, p. 104.

1883.]

Moris on, The Prurigo Papule.

343

ings, i. e., a hyperesthesia, and the eruption as only accidental. He
makes no difference between pruritus and prurigo.

A. Simon,1 in describing the minute anatomy of the papule, found the
epidermis intact, the papillae not enlarged, and the connective tissue not
changed. According to the author, the papule is, therefore, probably due
to a simple infiltration of the skin with serous fluid. He does not agree
with Hebra, that the fluid which escapes from a papule is contained in a
hair follicle.

WedP described the larger papules as often filled with a yellowish
fluid, and pierced with several hairs. The papillae were tinged with
blood, and red points could be seen similar to an injected loop of blood-
vessels.

Canuet3 explains lichen and prurigo as neuroses of the skin. In his
opinion both diseases agree in their premonitory symptoms and sequelae,
and only differ in the character of the eruption, which he considers of
secondary importance, and which may indeed be absent without, however,
affecting the intensity of the other symptoms. He considers that the
symptoms of both accord with those of a neurosis, and it is not infrequent
to see first lichen, then prurigo, indeed, sometimes, both diseases at the
same time, upon the same individual, coming from the same causes, and
appearing under the same circumstances. They are usually seen in ner-
vous individuals, especially in women, and in nearly half the cases after
a sudden emotion.

It can plainly be seen that this author does not consider prurigo as a
distinct disease in the sense of either Willan or Hebra.

Von Baerensprung4 does not consider the disease a neurosis. The
papules appear upon the skin, together with a feeling of increased warmth,
and are always without fluid contents. If torn with a needle, it is pos-
sible to draw out a sebaceous gland filled with a dense layer of cells, and
looking like a small sac. The papules are, therefore, not inflamed
papilke, but sebaceous glands, which, instead of secreting sebum, are
filled with epithelial cells, and this gives the paper-like dryness, and dirty
yellow colour to the skin.

Yon Veiel5 looks upon the disease as hereditary, and apparently does
not distinguish between it and pruritus, although he does not seem to
look upon the former as a neurosis. It usually skips one generation,
being handed down from grandparent to grandchild.

This author stands alone in his opinion, that the disease can be handed
down as an inheritance.

1 Die Hautkrankheiten (lurch Anatom. Untersuch. 1857.

2 Grundzuge der path. Histologie, Wien, 1851, p. 247.
s Gaz. des H6p. 1856, 126.

4 Ann. d. Charite zu Berlin, viii. 1858.

5 Prag. Vierteljahresschrift f. Prak. Heilk. 1862, p. 70.

344

Mori son, The Prurigo Papule.

[Oct.

Charcot and Vulpian,1 in treating cases of progressive locomotor ataxia
with nitrate of silver, noticed that sometimes an eruption resembling
prurigo would break out upon the whole body, but especially upon the
legs, and which would last as long as the silver was used.

Tilbury Fox2 describes the papules as pale, and due to an exudation
in the skin. They are caused by a disturbance in regeneration and inner-
vation, particularly in paresis of the nerves. Where there is a predispo-
sition to the disease, he considers that the prurigo papule may be accele-
rated in its development by the presence of parasites, or insects, and may
attain its customary appearance in consequence of scratching.

It was Schonlein who first pointed out the connection of the diseases of
the urinary organs to prurigo, and to this connection Eydam3 calls especial
attention by relating several instructive cases.

Derby4 found every papule pierced by a hair, and the external layer of
the sheath pouched where the hair muscle joined it. This pouch, com-
posed of epithelial cells similar to those of the sheath, and with which it
was in close connection, pushed itself between the cells of the muscle.
He describes also marked hypertrophy of the M. arrectores, the cells of
which appeared thicker than normal, sharply outlined, and granular ; the
hair itself more perpendicular, thinner, and very friable. Surrounding
the lower part of the hair sheath could be seen a large number of round,
shiny cells, which carmine coloured deeply. The bloodvessels of the hair,
the corium, and the papillae of the skin enlarged ; the cutis filled with
spaces surrounded by connective tissue, in which here and there exuda-
tion-cells could be seen. These spaces, according to the author, are due
to a serous exudation, which expands the normally very narrow lymph-
spaces, and which escapes from the papules when they are opened, as a
clear or rather bloody drop.

From his investigations is explained, according to Derby, why the
prurigo papule does not appear in places devoid of hair, such as the palm
of the hand, the sole of the foot, and also very seldom upon the flexor
side of the extremities, where few hairs grow. In an old case of prurigo
Derby found all the appearances so often seen in a chronic dermatitis,
such as lengthened and broadened papilla) ; the corium everywhere filled
with a serous fluid ; the rete Malpighii much thickened, its lower layer
of cells long drawn out, narrow, cylindrical, in the middle layer well-
defined prickle cells ; between both layers many wandering cells, in the
protoplasm of which brown pigment bodies were inclosed.

Gay,5 using the skin of a person ten years old, who died of pneumonia,
describes the changes found in pieces taken from various parts of the
body.

1 Bull, de Ther., t. Ixii. June, 1862.

2 Transact. St. Andrew's Med. Assoc. iii. 1869. 3 Deutsche Klin. 38-39, 1860.

4 Sitzgsb. d. Wien. Akad. B. LIX. H. 2.

5 Archiv f. Derm, und Syph. 1871, H. 1.

1883.]

Mori son, The Prurigo Papule.

345

He considers these changes divisible into two groups : the first, including
those of the rete Malpighii, and the organs standing in connection with it,
such as the hair sheaths and sweat glands ; and the second, including
those in the coriuui and papillae. In the rete Malpighii he describes cells
containing single or double nuclei, with their centres drawn in like a bis-
cuit. He calls attention to the extraordinary ease with which the nuclei
of many cells, as well as the cells themselves in the deeper layers, are
tino-ed with carmine. In severe cases these cells have the character of
horny epithelium ; there is also enlargement of the sweat glands and of
the vessels of the hair papillae.

The result of his investigations leads him to the following opinion :
The pruriginous process begins in the papillae of the corium, and the
tissue of the same is, after a dilatation of the vessels, which can be proven
to take place microscopically, much richer than normal in cells. After
this exudation, the rete Malpighii becomes infiltrated with small cells and
thickened, while the stratum corneum also becomes thickened, because
the upper layer of the rete Malpighii changes its character, and becomes
horny. Hand in hand with the changes in the rete Malpighii a cell infil-
tration occurs around the hair sheath. The increase in the cells of the
outer layer of the sheath is confined to single places, principally in the
neighbourhood of the muscles. The latter are hypertrophied. The sweat
glands take part in the process in the same intense manner as the hair
sheaths.

Hebra1 does not think it necessary to change his opinion since the first
edition of his book with regard to the anatomy of the prurigo papule.
He considers that it is, in all respects, like a vesicle, differing from the
latter only in the small amount of fluid contained in it, and in the thick-
ness of the epidermis which covers it. Further, that after a severe attack,
the glandular apparatus of the skin suffers through sympathy, and, lastly,
that the changes which one sees in chronic cases do not belong to prurigo
alone, but to any chronic disease which has affected the skin for a long time.

If one examines a lately affected piece of skin containing a single pru-
rigo papule, the papillae are found somewhat enlarged, tissues oedematous,
and containing a moderate number of cells covered with a stratum of epi-
dermis, containing in the deeper layers swollen-up or proliferating cells,
sometimes wandering cells. He considers that the papule of prurigo is
formed by a collection of fluid in the deeper layers of the epidermis, and
by the consequent elevation of its upper layers.

■ Klemm2 considers prurigo to be due to an affection of the nerves, and
that the papules follow the primary itching, as in herpes zoster, 'and,
according to this author, it has not been shown by experience that the
disease attacks by preference sickly children, or such as suffer from rha-
chitis, scrofula, etc.

1 Lehrbuch. der Hautkrankheiten, 1874. 2 Jah^, f. Kinderk. 4 H. 1374.

346

Moris on, The Prurigo Papule.

[Oct.

Eisenschutz,1 on the other hand, says that even the worst cases of pru-
ritus are never followed by a true prurigo, and does not agree with K. that
the itching is caused by the presence of serum and pus in the vesicles, or
that arsenic has any especial effect upon the disease.

Anstie2 does not distinguish between pruritus and prurigo, since he
speaks of prurigo senilis, meaning, in Hebra's sense, pruritus.

Duhring3 uses the term prurigo in the sense attached to it by Hebra,
and cites Hebra, Derby, Neumann, and Gay for the pathology of the
papule. In his ideas of the disease he differs from the majority of English
and American writers. It is a rare disease, according to this author, in
America and England as well as in France.

Piifard4 follows Hebra in the description of the disease.

O. Simon5 agrees on the whole with the descriptions of Derby, Gay, etc.,
but found quite the same changes from investigations of other chronic
inflammatory conditions of the skin, and would not accord to them any
pathognomonic signification for prurigo. Especially does this hold good
respecting the changes in the hair sheath and muscles.

Esoff,6 in examining normal skin, frequently found epithelial pouches
springing from the outer layer of the hair sheath, and these he divided
into two groups. To the first belong those which are not connected with
the M. arrectores, and also those described by Neumann as peculiar to
lichen ruber. These appear in the form of long pouches, which contain a
hair shaft.

To the second group belong those which are seen at the insertion of
the M. arrectores. These pouches also begin in the outer sheath layer,
and are a continuation of the same. In this group, both in respect to their
size and position, the author includes those pouches described by Gay and
Derby in prurigo.

Neumann7 considers the prurigo papule due to a cellular infiltration
and serous exudation of the papillae. The rete Malpighii is hypertrophied,
its cells rich in pigment. The papillae are enlarged, their tissue meshy,
the cutis thickened by tense connective tissue, the walls of the vessels
thickened in places, with an increase of cells of the external sheath layer.
The hair follicles are pouched out in the form of clubs, the smooth mus-
cular fibres hypertrophied. He considers that a careful study of the
nerves of the skin must be undertaken to decide whether or not an ana-
tomical change in them is not the cause of the disease.

Auspitz,8 reasoning upon the investigations of others, is of the opinion

1 Wiener, Rundschau. Sep. 1874.

2 Journ. Ment. Sc. xvi. April, 1870. 3 Diseases of the Skin, 1877.

4 An Elementary Treatise of Dis. of the Skin.

5 Berlin. Klin. Wochenschrift, No. 49, 1879.

6 Vierteljarhschft. fur Derm, und Syph. 1877, p. 595.

7 Lehrbuch der Hautkrankheiten, 1880.

8 System der Hautkrankheiten, 1881 ; Ziemssen, Hautkrankheiten, 1883, p. 193.

1883.]

Mori son, The Prurigo Papule.

347

that the papule of prurigo is nothing else than a kind of lichen pilaris, a
thickening of the epidermis around the lanugo-hair, or around the open-
ings of the sebaceous ducts. They do not have the slightest trace of an
inflammatory infiltration, as they are of the colour of the skin. They
remain papules, and never become vesicles or pustules, if they are not
scratched or rubbed. He considers that, if the papule does not belong to
an inflammatory process, which can be proven clinically and histologi-
cally (?), that if it is always in connection with a hair follicle, and if the
clinical resemblance with lichen pilaris and cutis anserina is not forgotten,
and, further, that if the itching cannot be explained as due to any inflam-
mation, he is justified in formulating the following explanation : Prurigo
is, like pruritus, a sensory neurosis of the skin. It differs from pruritus
by the primary appearance of papules, which, just in the same manner as
itching represents a sensory neurosis, represent themselves a contractile
neurosis of the skin. This is explained anatomically by the hypertrophy
of the smooth muscular fibres, and physiologically by the simultaneous
appearance of cutis anserina, which last, due to the constant cramp of
the muscles, produces a sort of tetanic contraction of the same.

Auspitz calls attention to the fact that he has frequently seen relapses
of prurigo, in which there was no doubt about the diagnosis, and where
there were all the symptoms of the disease, excepting the appearance of
the papules, and he considers it an open question whether, in such cases,
the proper diagnosis would be made in England or America, where it is
supposed so be so rare. He does not think that the papular eruption
plays in any way a more important part than' the never-failing sensory
neurosis, and so he considers the hypothesis that prurigo is really a com-
bination of a sensory with a contractile neurosis, sufficient to explain its
peculiar symptoms and its relation to pruritus cutaneus.

Kaposi1 does not consider it possible to ascribe anything peculiar to
prurigo microscopically after the consideration of his own and others' in-
vestigations. According to him, there is only a moderate infiltration with
serous imbibition of the papilke in the region of the papule, while the
changes in the rete Malpighii are the same as in eczema papulosum.
Where the disease has lasted for many years, there are the same changes
as in chronic dermatitis and chronic eczema, i. e., thickening; prolifera-
tion in the rete Malpighii ; scattered pigment in the corium, with largely
increased number of infiltration cells, especially marked around the vessels ;
here and there enlargement of the lymph spaces, as well as some of the
sweat glands by proliferation of their cells, in some places bulging of the
follicle, caused by the uneven growth of the sheaths ; thickening of the
M. arrectores, and, lastly, in old cases, atrophic degeneration of the fol-
licles and sebaceous glands.

1 Path. und. Ther. der Haut. 1883.

348

Mori son, The Prurigo Papule.

[Oct.

He does not consider that these anatomical changes explain the itching
or the localization of the process. It may be, as Hebra says, that the
former is caused by the fluid in the papule, but as such severe itching does
not occur in other circumscribed exudations (herpes and erythema papula-
turn), the theory is not entirely satisfactory while the localization and the
obstinate renewal of the papule is still unexplained. He does not consider
the disease a neurosis like pruritus cutaneus, on account of the percepti-
ble changes in the skin ; for he considers it certain that all the symptoms
of the disease go hand-in-hand with the increase or decrease of the pa-
pules. In pruritus cutaneus, no matter how long the duration of the dis-
ease, there are none of the signs of prurigo, there are no papules, and the
localization is not the same.

Behrend1 does not consider that the prurigo papule is always necessarily
pierced by a hair, or that the position of the papule is in connection with
the hair follicles. It holds a watery fluid and on this account he considers
the papule owes its formation to an exudation. The itching is brought
about by the irritation which this fluid exercises upon the sensory nerve
endings in the skin, and he holds that it is a secondary symptom just as it
is in urticaria, lichen ruber, etc.

He does not agree with Auspitz that it is a neurosis from clinical reasons.
It would be difficult, he says, to explain why the nerves, which are found
on the palm of the hand and soles of the feet, as well as those which regu-
late the skin on the flexor sides of the joints, always remain intact, and
that in these places in the most inveterate cases there is no itching, being
on this account never scratched. Further he does not consider that the
papule is due to a tetanic contraction of the arrectores pilorum, for the same
hypertrophic condition of the muscular fibres occurs, for instance, in ele-
phantiasis arabum, without there being anywhere the appearance of cutis
anserina .

In running over the opinions of those just cited, we see that they are
divided into two sets, first those who consider the disease a neurosis, and
second, those avIio do not. Those who consider it a neurosis (Willan,
Cazenave, Batemen, Alibert, Fox, and Auspitz) lay little stress upon the
pathological changes occurring in the papule, while those who do not con-
sider it a neurosis (Derby, v. Baerensprung, Gay, Hebra, Duhring, Simon,
Behrend, Neumann, and Kaposi) are divided into three groups. Derby
considers the changes due to the hairs. Hebra thinks the first appear-
ance of the papule is in the epidermis, while Gay and Neumann, etc., say
it is in the papillae.

The reason of the divergence of opinion about the pathology of the pa-
pule is due to the material used by the different investigators. One ex-
amined the skin from one stage of the disease, while the others took it from
other stages ; I shall return, however, to this question later on.

1 Lehrb. der Hautk. 1883.

1883.]

Moris on, The Prurigo Papule.

349

Having thus given a cursory description of the prurigo papule, accord-
ing to the opinions of others, I shall now proceed to describe the result of
my own investigations, and with the idea that the difference of opinion with
regard to the papule was due to the fact that the disease had not been
examined with sufficient care in its primary and later stages, I have tried,
as far as possible, to obtain the papules from patients affected with the
mildest form of the disease, as well as from those in whom it had made
such progress that it appeared in its most intense form.

Material has been furnished from seven different patients, from whom
twelve different pieces of skin have been excised intra vita?n, care being
taken to mark such papules as were most indistinct before excision with
India ink, and this was done in order that there might be no doubt that
the papule itself came under the field of the microscope. This was found
to be especially necessary with papules which could only be felt, as the
macroscopic changes in them were so slight that one could not be abso-
lutely sure of the position which they held in the section. In order to
give an idea of the different stages of the disease from which the skin was
taken I shall give a general outline of the seven cases referred to. As,
however, from these seven cases twelve different pieces of skin for exami-
nation were taken, I shall consider them as so many cases, it being my
object not necessarily to take them from different persons, but from dif-
ferent stages of the disease. The incisions in the skin were made deep
enough to include the corium, and in some cases part of the subcutaneous
tissue. The places were chosen with great care by Prof. Pick, and the
excisions made either by him, or under his supervision. With the proper
regulation of the treatment, and by intermitting it as required, the pru-
rigo papule can be obtained in its earliest and latest form, and while this
method of procedure enables one to obtain a clear idea of the papule mi-
croscopically, it also assists in its closer clinical study, which has a direct
bearing upon the history of the papule itself.

Case I. F. K., aged 10, entered hospital for the first time on Feb-
ruary 9th, 1883, affected with prurigo. The patient has been troubled
with itching from the earliest infancy. Parents and other members of the
family, consisting of four sisters and one brother, are all healthy. The eyes
of the patient have been congested for several years ; he also suffers from
nasal catarrh.

Status prcesens. The patient for his age is small, pale, and weak-looking.
His skin is somewhat pigmented, which is most noticeable on the trunk
and extremities, extensor sides. It is covered in the latter places with
somewhat elevated papules, which have bloody crusts upon them,
whereby the skin appears rough, uneven, dry, and thickened. The in-
guinal glands somewhat swollen, and the glands in other places more than
usually prominent. Was treated with glycerine, amylum powder, and
baths. After the skin had become soft and pliable, and the papules had all
disappeared, a piece was excised on February 21st, from extensor side of
the right humerus.

350

Mori son, The Prurigo Papule.

[Oct.

Case II. M. M., aged 7, entered hospital for first time on January
12, 1883, affected with prurigo. Mother died at 36 of phthisis. Two
other children at 8 and 11 years, respectively, are healthy. The present
affection, according to statement, has existed since the second year of her
life.

Status prcesens. Patient for her age is weak and undeveloped. The skin,
especially upon the extensor side of the extremities, rough, and covered
with scarcely visible prurigo papules. The glands generally are swollen.
Treated with baths, glycerine, and amylum powder, and sent out with a
smooth skin on March 11th. Returned to hospital on the 19th with a
well-marked prurigo eruption. On the 21st, before any treatment was
undergone, a piece of skin containing two papules was excised from the
extensor side of the humerus.

Case III. W. K., aged 17, entered hospital for the first time January
9th, affected with prurigo agria and acute nephritis. The disease showed
itself in his second year. It began upon the legs and spread gradually
over the whole body. His glands have been swollen for a long time.
Father of patient died of tuberculosis. The rest of the members of his
family are healthy. The house in which the patient lives is damp, and
for some time past he has been sleeping upon the floor. Patient coughs.
Treated in usual way, and sent from hospital February 6th, with a smooth
skin, and no albumen in urine. Returned to hospital March 26th, with a
reappearance of the disease. Three days after his entrance,* and before any
treatment was undergone, a piece of skin, containing a prurigo papule, was
excised from the calf of the left leg. '

Case IV. C. L., 12 years, entered hospital for the second time January
18th, affected with prurigo. There is no history showing that any other
members of the family have this disease. The eruption is just beginning
all over his body, but scattered here and there upon his hands and feet
are seen a few vesicles. One of these was excised. From a papule upon
his thigh, a hair was pulled out, great care being taken to bring with it as
much of its sheath as was possible.

Case V. Same as Case II. The patient, having been sent from the
hospital, returned after a while with a reappearance of the disease, and be-
fore any treatment was undergone, a piece of skin containing a papule
was excised from the extensor side of the left thigh on April 4th.

Case VI. Same as Case IV. A piece of skin taken from the thigh.
The eruption had become more prominent since the excision of the first
piece, which occurred two days before, as the patient had been subjected
to no treatment.

Case VII. F. N., 11 years old, entered hospital for the first time Feb-
ruary 8, 1883, suffering from prurigo. The patient is the only one of a
family of eight children thus affected. From his infancy has been trou-
bled with severe itching, which was especially bad upon his legs.

Status prcesens. The patient looks pale, and is of small stature. The
skin of the trunk is somewhat pigmented, and scattered here and there
upon it are seen pin-head-sized papules covered with bloody crusts.
These, including pustules, are present also in large numbers upon the ex-
tensor sides of the extremities. On the legs, in their whole circumference,
there are large confluent pustules in some places forming ulcers. The
glands are swollen everywhere. On April 12th, and while the disease was
in a complete state of eruption, a papule was excised from the left arm.

1883.]

Mori son, The Prurigo Papule.

351

Case YIIT. Same as Case III. A piece of skin containing a papule
was excised from the extensor side of the thigh on April 19th, after a
week's intermission of treatment, and when the eruption was just begin-
ning to appear.

Case IX. J. K., aged 26, entered hospital, where she had been treated
many times before, on March 30th, affected with prurigo. The eruption
extends over the whole body, and began with itching in her earliest
infancy. Her menses have been regular since her 16th year. The pa-
tient is strong, well-built, and well-nourished. Her skin is pigmented
and rough, especially so on the extensor sides of the extremities, which
are covered with scratched and unscratched papules. Inguinal glands
much swollen. Pediculi vestimentorum. After a long treatment with
baths, solutio Vleminckx, etc., the papules all disappeared, and the skin
remained simply pigmented and thickened. In this state a piece of skin
was taken from the right thigh, extensor side, on May 1st.

Case X. Same as Case II. After a period of treatment, during which
the skin became apparently normal, the patient was left alone for a week,
and just as a relapse was beginning, a prurigo papule, which could be
more plainly felt than seen, was taken from the right thigh. It did not
differ from the skin in colour, was very slightly raised, and had not been
scratched. Before excision it was marked with India ink, and afterwards
placed immediately in absolute alcohol.

Case XI. W. M., aged 11 years, entered the hospital for the first time
May 27, 1883, affected with prurigo. The disease has lasted a year and
a half, and began, according to his statement, with the formation of
papules. His parents, two brothers, and one sister are healthy.

Status prsesens. Patient, for his age, is abnormally well developed,
his skin is rough and pigmented upon the extensor sides of the extremities,
where it is thickened and covered with papules, and shows, from the
bloody-looking crusts which cover the various pustules and small ulcers,
the extent to which scratching has been carried. The inguinal glands on
both sides swollen to the size of a walnut. On the day following his en-
trance, and before treatment had begun, a piece of skin containing a
papule was taken from the right arm above the elbow-joint. This papule
had not been scratched, and although less prominent than any of the
others, it could be plainly seen and felt. Before excision it was marked
with India ink.

Case XII. Same as Case I. After undergoing treatment for some time
until the skin had become to all appearances normal, the patient was left
alone for a few days and carefully watched, in order that a papule might
be excised in its earliest stage. As soon as one was felt, and when it was
not even visible to the unaided eye, it was marked with India ink and
then excised.

The clinical histories of the cases have been given in the order in which
the material was taken from the patients, but in making a histological
description, I shall begin with that papule which appears in the earliest
stage of the disease, and shall for this reason choose Case XII. as the
first one to be described.

From Case XII., which had undergone treatment, and in which the
disease was just beginning to reappear, a piece of skin 1 cm. long and -J
cm. wide, was cut from the left thigh, extensor side. It contained one

352

Moris on, The Prurigo Papule.

[Oct.

papule which could be plainly felt as a body about the size of a millet-
seed, but could not be seen without the aid of a magnifying glass, and
this showed it to be slightly raised above the rest of the skin in the form
of a rounded elevation. The other part of this piece of skin was soft and
pliable like normal skin, and there were no appearances of its having been
scratched, showing that no itching had previously existed. Before its
excision the papule was marked with India ink, and the whole piece then
hardened in alcohol. This piece of skin was cut into a series of thirty-six
sections, the first one beginning at the edge of the papule. They were
then stained in gentian violet and mounted according to their order in
Canada balsam.

The microscope disclosed two hairs which pierced the papule in its
centre, and near them, running to its surface, the duct of a sweat gland
also. In the papillae lying between the hairs is seen a slight amount of
round-cell infiltration, which in those sections corresponding to the middle
of the papule is most intense around the upper layer of vessels of the
corium, or where the papillary vessels join them. The papillae are some-
what elongated, and a few infiltration cells surround their vessels, the
hair sheaths, and glandular duct. The M. arrectores are not hyper-
trophied, and there is a slight bulging of the whole portion of the skin
which lies above the infiltration, and which includes ten or fifteen papillae
counted as they appear on the flat surface of the section. Both hair
sheaths are slightly pouched and uneven, corresponding to the changes
described by Derby, Gay, and Neumann, but the sebaceous and sweat
glands are unaltered. The infiltration in this specimen, starting from the
upper layer of vessels of the corium, extends upward as far as the rete
Malpighii and there stops. The epidermis is not thicker above the infil-
tration than elsewhere in the section, and in it, quite unaltered, are seen
the elongated cells of the first layer of the rete mucosum, the well-defined
prickle-cells, the stratum granulosum, the stratum lucidum, and then the
horny layer, to which the India ink clings, marking the exact position of
the papule. In none of the sections is the slightest trace of a vesicle to
be seen, or any of those small heaps of 'scaly epithelium which characterize
the epidermis of the cases taken from a later stage of the disease.

The other portions of the skin, adjacent to the papule, have a few wander-
ing cells scattered here and there around the vessels, but otherwise there is
no change from the normal.

Fig. 1 shows well the microscopical changes, which consist, as has been
described, simply in a small amount of round-cell infiltration.

From Case X., which was a little further advanced than the previous
one, a piece of skin ^ cm. wide and 1 cm. long, and containing a papule,
plainly felt as a body somewhat larger than a millet seed, but which was
scarcely visible, was cut from the extensor side of the right thigh, and
the papule having been previously marked with India ink, the whole

1883.]

Mori son, The Prurigo Papule.

353

piece was placed in alcohol. The adjacent skin was to all appearances
normal, and had not been scratched.

This piece of skin was cut into a series of thirty sections, the first one
being made at the edge of the papule, and after staining with gentian
violet they were mounted according to their order in Canada balsam.

Fig. L.

The papule lies between A and B. I. Infiltration. H. Hairs. S. Opening of a sweat duct.
(Oc. 3 ; ob. 4. Reichert.)

As in Case XII. the infiltration was seen to be most intense around the
upper layer of vessels of the corium, and where the papillary vessels joined
them. From this point it runs up into the papillae, stopping at the
rete Malpighii. Three hairs pierce the papule, and there is a sweat- duct
running through it. The infiltration surrounds the vessels lying between
the hairs, but does not affect the sebaceous glands, which are quite un-
changed. There is no appearance of hypertrophy in the M. arrectores,
nor are the sudoriparous glands, the entire duct of one of which is seen
passing through one section, altered in any way. The papule includes
ten or fifteen papillae which are more or less infiltrated and decidedly
enlongated. The epidermis covering them is somewhat thicker than in
other parts of the skin.

In running over this series the infiltration is seen surrounding the ves-
sels, which run down between the hairs, and the hair sheaths appear
somewhat pouched, as in Case XII. The skin adjacent to the papule is
not altogether normal, for the vessels are slightly enlarged and there are
a few wandering cells in their neighbourhood. The epidermis is generally
thicker than is normal, but there are no appearances of a vesicle any-
No. CLXXII Oct. 1883. 23

354

Morison, The Prurigo Papule. [Oct.

where to be seen. The openings of the sweat-ducts are slighly dilated,
and the connective tissue of the corium is only slightly irregular in that
portion included within the papule.

From Case XI. which had reached the acme of the disease, a piece of
skin about 1 cm. square, containing a papule slightly larger than the
other two already described, and which could be plainly seen, was taken
from the left arm, just above the elbow-joint. Before excision the papule
was marked with India ink, and the whole piece then placed in alcohol.
Although more prominent than those of Cases XII. and X., the papule itself
had not been scratched, but the adjacent skin, from previous irritation,
had become somewhat harder and thicker than normal.

This piece was cut into a series of twenty-four sections beginning at the
edge of the papule, and after staining with gentian violet they were
mounted according to their order in Canada balsam.

The changes in this case are similar to those in the previous one. The
infiltration is seen to start from the same place in the corium, and extends
upwards surrounding the papillary vessels. In this papule there are no
hairs, but there is a sudoriparous duct running through it, around which
there is also a moderate degree of small cell infiltration. The papilla? are
somewhat elongated, and the stratum corneum covering the papule slightly
thickened. There are two sweat-glands lying almost directly under the
primary infiltration which are unaltered. Surrounding them are seen a
few wandering cells. In the skin adjacent to the papule the vessels are
slightly enlarged, and here and there a few infiltration cells are seen near
them. There is nowhere any appearance of a commencing vesicle, or of
the scattered heaps of epithelial cells to be noticed further on. The fibres
of the connective tissue of the corium, with the exception of those included
in the papule which are slightly irregular, are not altered.

In the skin adjacent to the papule, the stratum corneum is somewhat
thicker than normal, and there is a slight degree of infiltration scattered
around the vessels of the papillas and corium. (See Fig. 2.)

From Case II., which was at the acme of the disease, a piece of skin,
■J cm. wide and 1-| cm. long, and containing two papules, each about
the size of the head of a pin, and which could be plainly felt and seen,
was cut from the extensor side of the right humerus. There was no series
made in this case, but the entire papules were included in the sections,
and, after staining with carmine, Bismark brown, and gentian violet, they
were all mounted, without however being arranged in any particular order.
It required but little care to pick out the sections which came next to each
other.

One of the papules is pierced by twro hairs, which however run through
its outer edge and not through its centre. There is a comparatively large
amount of cell infiltration around the upper vessels of the corium and those
running into the papillae. This infiltration, independent of the hairs, and

1883.]

Mori son, The Prurigo Papule.

355

not surrounding them, is seen to pass through the epidermis, between the
layers of which a vesicle has formed, which also is not pierced by the
hairs. This vesicle lies within the epidermis, between the stratum granu-
losum and stratum corneum, involving the former to a slight degree, and

Fig. 2.

The papule lies between A and B. I. Infiltration. S. Opening of sweat duct with gland
underneath. (Oc. 3 ; ob. 4. Reichert.)

covering the middle portion of the papule. It is not more than half the
circumference of the papule, for there are as many as fifteen papilla?
included in the latter and only half that number are covered by the
vesicle.

The vesicle is similar to those seen in other diseases (variola, herpes
zoster, etc.), and its contents consist of the infiltration cells, which have
come from the corium, with broken-down epithelium. This infiltration is
seen passing through the different layers of the epidermis, and the cells
can be followed into the vesicle itself. It is confined to that portion of
the skin included in the papule, and does not extend downwards beyond
the upper line of vessels running through the corium. The muscles are
not hypertrophied, and the hair sheath is not altered.

The second papule, included within these sections, has the duct of a
sweat gland running to the surface of the epidermis directly through its
centre. The infiltration is seen to occupy the same place as in the first
papule. It extends upwards, surrounding the sweat duct, passes through

356

Mori sox, The Prurigo Papule.

[Oct.

the rete Malpighii, and between the same layers of the epidermis as in
the one just described, and, surrounding the opening of the duct, a vesicle
has formed, within which can be seen some of the infiltration cells. This
vesicle is larger and more distinct than the former one, and its contents
evidently more fluid than it, as the meshes are larger and the trabecular

running across it longer. It does not.
however, any more than the previous
one, cover the whole surface occupied
by the papule.

There are no hairs running through
this papule, and the infiltration is con-
fined to the upper portion of the cori-
um, the papilla?, and epidermis. The
latter is thickened where it covers the
papillre included within the papule.

In the adjacent skin there is a small
amount of infiltration, surrounding
sometimes the hair sheaths and sweat
glands, but always surrounding the
vessels. On the surface of the epi-
dermis, surrounding the hair follicles
and covering the openings of the sweat
ducts, are seen in many parts of these
sections a small collection of epithelial
cells, which cling either to the hair or
are attached to the ducts. They are
simply scales of epithelium which have
not fallen off. All along the lower
layer of the rete -Malpighii there is
seen a marked increase in the amount
of brown pigment contained within
the cells. Itching had evidently been
severe, as the macroscopic appearances
of the skin showed, but the vesicles
upon these papules were still intact.

In this case the papules were the
direct result of the infiltration de-
scribed, while all the other changes in
the cutis and epidermis were second-
ary. (See Figs. 3 and 4.)

From Case III., which had reached
the acme of the disease, a piece of
skin, \ cm. square, was taken from
the calf of the left leg. It contained

.2 «

1883.]

Mori son, The Prurigo Papule.

357

a papule the size of a pin head, which could be plainly felt and seen. A
series of thirty sections was made, and they were mounted in regular

order in Canada balsam after having been stained with gentian violet.
The papule was pierced by a hair, and contained the duct of a sweat
gland. All the sections presented the appearance so commonly seen in

358

Mori son, The Prurigo Papule.

[Oct.

chronic inflammations of the skin, and it was only from the greater thick-
ness of the epidermis and the large amount of cell infiltration at one point
in the sections, that the papule could be distinguished from the rest of the
skin.

As in chronic dermatitis and eczema, there was general thickening of
the rete Malpighii, increase in the quantity of pigment in its lower layers,
collections of infiltration cells here and there, especially marked around
the vessels, enlargement of the lymph spaces, with hypertrophy of the hair
muscles. There were also seen at various points, as is so frequently the
case even in normal skin, where the stratum corneum from any cause is
thickened (lichen pilaris), curled up underneath the epidermis, encysted
hairs.

There was no vesicle in this series, but at various points along the sur-
face of the epidermis the same small heaps of scaly epithelium were seen
which have already been described.

From Case IV. a piece of skin about cm. square, and containing a
vesicle which had the appearance of belonging to a papule, was taken from
the inside surface of the left foot. This piece was cut out so superficially
that nothing but the vesicle itself with its upper and lower layers of epi-
dermis was left. The sections made, therefore, could not have any bear-
ing upon this subject.

From a papule on the extensor side of the left thigh, a hair was care-
fully pulled from its follicle with the epilation forceps. Almost the entire
sheath came away with it. Under the microscope it was found to contain
two hairs, and one of these was so much curled up that it was almost im-
possible to follow its course. The sebaceous gland filled with epithelium
cells such as v. Baerensprung describes, was not found.

From Case V. in the acme of the disease, a piece of skin -| cm. wide
and 1 cm. long, and containing a papule about the size of a millet seed,
was cut from the extensor side of the left thigh. There was no series
made in this case. The sections wrere stained in gentian violet and picro-
carmine, and mounted in Canada balsam or glycerine. The papule was
formed in the same manner as in the previous cases, by an infiltration
commencing around the vessels of the corium and extending into the pa-
pillae. Through the outer edge of one side runs the duct of the sweat-
gland. A small vesicle has formed in the epidermis surrounding the
sweat-duct as it passes through it. It is similar to those already de-
scribed, but much smaller. Where the hairs pierce the epidermis it is
pushed up, giving the impression that the stratum corneum resisted them
as they passed through.

In these sections great care was taken to examine the substance called
by Ranvier1 eleidine, and for/which the name of " kerato-hyaline" has been

1 Sur une substance nouvelle de l'epiderme et sur le processus de keratisation du
revetement epidermique. Comptes rendus, 1879, t. 88, p. 1361.

1883.]

M o R i s o n , The Prurigo Papule.

359

proposed by Waldeyer,1 for the purpose of comparing it with the amount
contained in normal skin taken from the same situation.

It was found to be largely increased, but not to a greater extent than
it -was in other diseases in which the rete Malpighii and epidermis are in-
filtrated or thickened (molluscum contagiosum, pemphigus.) Where the
epidermis was seen to be thickest, there the eleidine was increased pro-
portionately, for instance, just underneath the vesicle and where the hairs
passed through.

From Case VII. a piece of skin ^ cm. wide and 1 cm. long, contain-
ing a papule, was cut from the extensor side of the left humerus. This
papule was pierced by a hair, but the infiltration was more intense around
the vessels in its neighbourhood than around its sheath. There was
general thickening of the epidermis, but especially in that portion cover-
ing the papule. In the adjacent portions of the skin, the changes were
present which have been so often ascribed to chronic inflammations.

From Case I., which on account of treatment had no appearance of the
disease, a piece of skin -J cm. wide and cm. long, was cut from the
extensor side of the right humerus. A small amount of cell infiltration is
seen lying around the vessels of the corium and the papillee. The latter
are somewhat elongated, there is an increase in the amount of pigment
bodies in the lower layer of the rete Malpighii, the epidermis is thickened,
the openings of the ducts are dilated and are covered in many places with
small collections of scaly epithelium. The hair sheaths are pouched at
the insertion of the muscles, and in many places encysted hairs are curled
up underneath the epidermis. The M. arrectores are hypertrophied.

These changes are spread evenly throughout the skin, and there is no
evidence of a central infiltration, as in those cases where there is a papule.

From Case IX., which on account of treatment had no appearance of
papules or of scratching, a piece of skin ^ cm. wide and nearly 2 cm.
long, was cut from the extensor side of the right thigh. There was no
series made with this piece. The sections were mounted in glycerine or
Canada balsam, after staining with carmine, picro-carmine, Bismark
brown, and gentian violet. They all contained evidences of chronic in-
flammation.

In those sections stained with picro-carmine the eleidine, as in Case V.
was seen to be increased. There was general thickening of the epidermis,
and in many places the hairs were encysted.

From Case V. a piece of skin 1 cm. square and containing a papule,
was taken from the extensor side of the right thigh. There was no series
made, and the sections were all placed either in chloride of gold, or hyper-
osmic acid, for the purpose of examining the nerve endings. Neither the
tactile corpuscles nor the nerves themselves were seen to be altered.

1 U tersuchungen fiber die Histogenese der Horngebilde insbescmdere der Haare und
Federn,'1881. Henle Celebration, Gottingeu.

360

Mori sox, The Prurigo Papule.

[Oct.

From Case VIII. a piece of skin about \ cm. wide and 1 cm. long
and containing a papule, was cut from the extensor side of the left thigh.
The sections were all placed either in chloride of gold or hyperosmic acid.
As in Case VI. no change was seen in the tactile corpuscles or the nerves
themselves.

In making a summary of my own investigations, although acknowledg-
ing that I have found no changes which have not been described by
others, excepting the eleidine, yet I am forced to draw rather different
conclusions regarding the formation of the papules, when considering
them in their earliest and latest stages.

I consider that the papule is formed by an infiltration beginning around
the upper layer of vessels of the corium, and that this infiltration extend-
ing upward surrounds the papillary vessels, enlarges the papilla3, thus
pushing up the epidermis, which becomes thickened at an early stage above
them, and at last penetrating it, forms within its layers a small vesicle
containing serum, blood, and lymph-cells. The signs of infiltration sur-
rounding the hair sheaths and sweat-ducts are secondary, and they play
no especial part in the process. Their presence in the papule is accidental,
and it is certain that the primary changes in the skin are not in connec-
tion with them.

The colour of the papule at first does not differ from the rest of the sur-
rounding skin, on account of the depth of the slight infiltration with which
it begins. For the same reason, it is at first only felt, and not seen, as
the infiltration has not extended high enough to push up the epidermis
perceptibly, but is sufficiently great to give a feeling of knot-like hardness
underneath it. I differ, therefore, entirely with Auspitz when he says
that the papule does not belong to an inflammatory process. In fact, I
consider the whole process due to an inflammation, and that all the signs
of chronic dermatitis follow regularly, according to the length and dura-
tion of the disease, and the amount of scratching, which the itching, as a
secondary symptom, causes.

Clinically the formation of the papule coincides with the foregoing
description, for there is always noticed in the beginning of the disease,
after careful investigation of the skin, a slight roughness, and a sensation
as of running the hand or finger over small knots, covered with an inter-
vening membrane. At this stage there is no itching. In fact, the itch-
ing does not begin until the infiltration has so far advanced that the
papules are more distinct. If before this occurs the treatment is begun,
no itching appears. This proves, as Kaposi says, that all the symptoms of
the disease go hand in hand with the increase or decrease of the papules.

In looking over the work done by others, and comparing it with my
own investigations, I find that they disagree more in the conclusions
arrived at than in the general histological changes described.

I cannot agree with Hebra that the formation of the papule begins in

1883.]

Mori son, The Prurigo Papule.

361

the layers of the epidermis, and that the itching is due to fluid contained
within the vesicle ; for, in those papules taken from the earliest state of
the disease which I examined, there is no sign of a change in the epi-
dermis. This is not affected until the infiltration has become more gen-
eral, and in several cases the itching was present before a vesicle ivas
seen, macroscopically or microscopically. Nor can I agree with Derby
and Auspitz that the papule is always pierced by a hair, for, in several of
the papules examined by me, there was no hair to be seen.

I must also disagree with v. Baerensprung, that they are due to a col-
lection of epithelial cells within the openings of the sebaceous ducts ; for
this collection of epithelial cells does not occur until the stratum corneum
is so affected that a proliferation of its cells takes place, causing an extra
formation of scaly epithelium, which generally falls off, but which often
clings to the hair-follicles and openings of the sweat-ducts in the form of
small heaps. These masses have nothing to do with the papule, and may
occur in any disease, causing chronic thickening of the epidermis.

The investigations of Neumann, Gay, and Simon coincide more nearly
with my own, but I do not agree with them that the infiltration begins in
the papillae. These are affected later, and the part of the cutis, where the
inflammation first occurs, is underneath them, around the vessels of the
corium, and where they send off smaller branches to the papillae.

If asked what was the cause of the inflammation starting the formation
of the papule, I must honestly answer, I do not know. Auspitz is satis-
fied with the hypothesis, that it is an idio-neurosis, but his conclusions are
drawn without a thorough consideration of the pathology of the papule.
He takes it for granted there is no question of a primary inflammatory
condition, a statement which is utterly at variance with my own micro-
scopical investigations, and those of others. He seems to me to begin at
the wrong end of the papule, for, as I have shown, the hypertrophy of the
hair muscles does not occur any sooner in prurigo than in some other affec-
tions where there are no papules. As, however, they are not always in
connection with a hair, it is not necessary to further argue this point.

Late investigations into the condition of the nerve endings in ichthy-
osis1 and vitiligo2 have shown them to be altered. Still the question
immediately suggests itself whether these changes were not the result of
disease rather than the cause. Would there not be changes in all parts of
the skin, as the natural result of a chronic diseased condition ? Some
authors think that one proof of a disease having a nerve origin would be
its production by the use of drugs known to affect them. The description
by Charcot and Vulpian of a pruriginous eruption, produced by nitrate of

1 Leloir, Alteration des nerfs cutanes dans un cas d'ichthyose congenitale. Comptes
Rend., t. 89.

2 Leloir et Chabrier, Alterations des nerfs dans un cas de vitiligo. Comptes Rend.,
t. 89. '

362

Connek, Excisions of the Tarsus.

[Oct.

silver, would carry much weight with it, if others had confirmed it, or had
the symptoms coincided with those of prurigo, but as it stands it is unim-
portant, and proves nothing.

Until more thorough proof based upon careful pathological investiga-
tions is produced, I cannot look upon prurigo as a neurosis. The appear-
ance of the papules, caused by a primary infiltration and inflammation
before the itching, the peculiar localization of the disease, the negative
effect produced by " nervines" therapeutically, the distinct and character-
istic eruption which distinguishes it from other diseases, the fact that a
simple itching (pruritus) never runs into it, speak altogether against this
hypothesis.

The connection of 'many diseases of the skin with albuminuria has often
been noticed, so that prurigo does not stand alone in this respect. Where
they occur together, the albuminuria, as in the case related in this paper,
generally disappears with the improvement in the prurigo symptoms.
There are, however, so many cases of prurigo which have no connection
with a disease of the kidneys, that the two occurring together is to be ex-
plained rather as an accident, than that they have any direct bearing upon
each other.

Hebra and all other observers, except Klemm, consider the disease
most frequent in ill-nourished and ill-cared-for people, but to explain a
disease by saying it is due to a " bad state of the system" is illogical and
unscientific, and therefore I must consider that the first cause which pro-
duces the inflammation in prurigo is still unexplained.

I cannot close this article without expressing my warmest thanks both
to Professor Chiari and to Professor Pick for the kind assistance which
they have rendered me while investigating this subject, and for the friendly
interest which they have manifested in all my work during my stay in
Prague.

Prague, June 22, 1883.

Article III.

EXCISIOXS OF THE TARSUS, WITH A KEPORT OF TWO SUCCESSFUL RE-
MOVALS of the Entire Tarsus. By P. S. Coxxer, M.D., Prof, of
Anatomy and Clinical Surgery, Medical College of Ohio, etc.1

Admirably adapted as is the foot to sustain weight, diffuse force, and
secure ease and quickness of movement, it is, in its proximal half at least,
peculiarly liable to disease and the extension of inflammation from part to
part. Placed where it must, of necessity, be subjected to violent jars and

1 A paper read before the American Surgical Association, at its meeting at Cincin-
nati, Ohio, June 1, 1883.

1883.]

Conner, Excisions of the Tarsus.

363

severe twists, every opportunity is afforded for the occurrence of limited
blood-extravasations in its bones, and of traumatic synovitis in its joints.

Its skeleton is made up almost entirely of cancellous tissue, covered in
by closely adherent periosteum, that blends so intimately with the liga-
ments of the numerous articulations that it may, surgically considered,
be regarded as a single sheet inclosing the whole tarsus.

It is crossed by numerous tendons and overlain by a definite though not
very thick sheet of connective tissue, so that thecal and fascial inflamma-
tions may readily, by contiguity, be carried over to it.

In those who, by possession of the ignotum quid, are predisposed to the
so-called strumous affections, the frequently occurring, usually slight,
traumatisms may readily be followed by simple inflammation, or by the
deposit of tubercle in the bones, the synovial membranes, or the peri-
articular structures.

Specific periostitis or gumma may be here located, to produce the same
effects as elsewhere. Lastly, external violence, contusions, cuts, com-
pound fractures (gunshot or other), may be the developing cause of
caries or necrosis.

Little wonder is it then, that tarsal disease is of frequent occurrence,
or that it is at times found to affect a large portion or the whole of this
section of the foot.

When thus extensive, what shall be done for its relief? Rest, compres-
sion, and stimulating or sedative applications (always proper in the be-
ginning, and at times securing the best of results) are very likely to fail
in arresting the progress of the disease, which more or less rapidly goes
on to the destruction of the part.

When such has been produced, when the peri-articular structures are
greatly thickened, abscesses have formed, and numerous sinuses exist
leading down to dead bone, surgical interference is limited to : 1. The
opening of the abscess cavity, and the informal removal of carious or
necrosed tissue, with or without deep cauterizations or such local stimulant
applications as shall tend to secure more healthy and reparative action;
2. Amputation, usually at or above the ankle-joint ; and, 3. The method-
ical excision of such and so many of the tarsal bones as are unhealthy.

The first method in one form or another has long been employed, and
in the less severe cases may be expected to often, perhaps generally, re-
sult favourably.

It is under this head that we must place the use of the actual cautery,
so highly commended by Oilier and others of the French surgeons; the
evidement of Sedillot ; and the gouging and oakum-seton method of- our
distinguished Fellow, Dr. Sayre.

By surgeons generally, amputation through the leg or at the ankle has
been and still is regarded as much to be preferred to any more conservative
treatment.

364

Conner, Excisions of the Tarsus.

[Oct.

Such operation, it is claimed, is less likely to be followed by death from
septic infection, or as the result of protracted and profuse suppuration ;
and leaves the patient in a better local condition, more able by the aid of
an artificial limb to move about and earn a livelihood.

But there have been reported from time to time, especially during the last
twenty years, cases of extensive formal excisions, the history and end-
results of which compel a reconsideration of the alleged dangers and dis-
advantages attending an attempt to remove the diseased and preserve the
healthy part of the foot.

Such attempt, it has been held, may cause death, at first or later ; will
very likely be followed by a return of the disease in the parts left ; and
even if successful as respects life, must leave a useless foot, if not one
actually an incumbrance.

Before proceeding to determine, if possible, the correctness or incor-
rectness of these views by an analysis of the 108 excisions of two or
more bones which I have been able to collect, permit me to briefly report
two cases in each of which removal of the entire tarsus was recovered
from, and a very serviceable foot secured.

Case I— A. S., Alsatian, ret. 39. First seen July 18, 1875. For
about two years had had disease of the right tarsus, following, as claimed,
a slight injury upon the outer side of the foot.

General condition bad, consequent upon suffering and profuse suppura-
tion and a very recent attack of erysipelas extending up to the middle of
the thigh. The posterior half of the foot was much enlarged, and through
four openings over the ankle and heel the probe could be readily passed
into carious bone.

Excision being determined upon, on the following day, July 19, 1875,
the entire tarsus, every bone of which was more or less diseased, was re-
moved through an external lateral incision, extending back to the outer
border of the tendo Achillis. The upper articular surface of the astrag-
alus, though healthy, was taken away with the rest of the bone, but the
malleoli were left untouched. The resulting cavity was lightly packed
with carbolized oakum, and the limb placed in a fracture -box.

A high temperature (105° F.) was noted at the end of the first
twenty-four hours ; but thirty-six hours later. Dr. Schwagmeyer, who had
the immediate care of the case, reported to me : "Patient quite comfort-
able, very little fever, more appetite, tongue moist, complains of but little
pain, has had several hours quiet sleep." From this time on, the progress
toward recovery was steady, and in a little less than two months the
wound was entirely closed.

It is, perhaps, a significant fact, with reference to the cause of the tar-
sal disease, that just before this complete cicatrization occurred, the man
had quite a severe acute periostitis of the left tibia in its upper third,
which soon disappeared under the administration of full doses of the
iodide of potassium.

This case, so far as I have been able to ascertain, was the first in which
the entire tarsus was taken away.

1883.]

Conner, Excisions of the Tarsus.

365

In Jaesche's case, which was reported nine years previously, there was
left of the os calcis, " the posterior part of the crust in form of half an egg-
shell," to which the tendo Achiilis was attached.

At the present time the man (not using even a cane) walks firmly and
rapidly without limp, and can easily and quickly go up and down stairs,
or climb up on to his wagon-seat. There is a half-inch shortening of the
leg ; the lateral movements of the foot are slightly limited ; and the
range of flexion and extension of foot on leg is lessened about one-fourth.
The sole is flattened, but there is no lateral deviation of the foot or eleva-
tion of border. No re-formation of bone seems to have taken place.
The foot is three inches shorter than its fellow (7 in 10 in.); the circum-
ference at instep level is one-fourth inch greater (9 in. — 8| in.); measured
over the heel and just below the malleoli the circumference is one-fourth
inch less (11 J in — 12 in.).

Case II E. S., a?t. 20, German. First seen in Cincinnati Hospital

April 1, 1876. Had had for over two years disease of the right tarsus.
Had already been twice operated upon by Dr. B. F. Miller, the "scaphoid
and most of the astragalus" having been taken away in April, 1875, and
three and a half months later " some small pieces of necrosed bone and a
part of the os calcis." Examination of the foot showing that much, if not
all, of what remained of the tarsus was carious, on the 8th of April I re-
moved the whole of it through an external lateral incision.

The after-treatment was similar to that of Case I. As in that case
there was an early rise of temperature (103° F.) at the end of the first
twenty-four hours, with quick decline. Healing went on steadily, but
slowly, and it was nearly six months before the man was able to readily
move about without crutches.

Seven and a half months after the operation he could walk very well,
and was doing duty as a nurse in the hospital ward. He now walks with
ease and quite rapidly ; never uses a cane ; can run up and down stairs ;
and says that, so far as he can tell, the ankle movements are as good as
ever. Their range does not seem to be any less than that of the sound
ankle. Lateral movement is a little restricted. Owing undoubtedly to
too great use of the foot soon after passing from under my observation,
the leg bones have been crowded downwards and inwards; but no eleva-
tion of the outer border of the foot has taken place. The leg is shortened

three-fourths of an inch, and the foot two and a half inches (7 in -9^ in.).

The instep circumference is one and a quarter inch less (7^ in 8-^ in.) ;

that over heel and below the malleoli two inches less (9^ in ll|- in.) ;

that at level of base of toes one inch less (7^ in 8^ in.) than the like

measurements of the left foot.

Satisfactory as has been the end-result in each of these two excisions,
has it been merely surgical good fortune, or have we a reasonable pros-
pect of securing the like in similar conditions of the foot? Though the
number of operations tabulated is limited, it is yet, I believe, sufficiently
large to warrant the deducing therefrom of certain general conclusions ;
especially since they have been made by many operators in various places
and under diverse conditions, as respects time, age, and personal character.

1883.]

Conner, Excisions of the Tarsus.

367

358

Conner, Excisions of the Tarsus.

[Oct.

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Conner, Excisions of the Tarsus.

376 Conner, Excisions of the Tarsus. [Oct.

The three questions to be considered are : —

1. Is excision a safe operation, or at least attended with no greater mor-
tality than the alternative — amputation ?

2. Is it likely to put an end to the disease, or is recurrence of the mor-
bid process in the unremoved bones of the foot to be expected?

3. Will the patient, after recovery from the operation, be left with a
serviceable limb ?

Of the 108 cases collected, 11 died (10.18 pr. ct.), but 1 of them died
of amyloid disease in ten days, and 1 of phthisis in a month, and, if we
deduct these cases, in neither of which was the fatal result due to the
operation, the mortality is reduced to 8.33 pr. ct. ; and if Tiling's case is
thrown out, in which, after gunshot injury, intermediary excision was
made, followed by amputation five days later, and by death from gangrene
in another five days, the percentage is reduced to 7.4.

Of the 9 fatal cases (including Tiling's) in 4, at the lowest, a Syme
amputation and in 5 a Chopart would have had to be performed; or, to
put it in other words, out of G3 cases, in which the alternative was an
ankle-joint amputation, 4 died (6.35 pr. ct.) ; and out of 45, in which a
middle tarsal removal might have been made (though without doubt in
some of them a Syme or Pirogoff amputation would have been performed),
5 died (11.11 pr. ct.).

The Syme operation mortality for caries is about 6 to 8 pr. ct. (at least
10 pr. ct. according to Delorme), the Pirogoff probably about the same,
and the Chopart perhaps 4 pr. ct., though Schede has placed it as high as
10 pr. ct.

Examination of the table further shows, that while it is true that ex-
cision is attended with very much less mortality in young subjects, the
opinion expressed by certain writers that it should be confined to them, is
not warranted by the facts.

Of 87 cases, the ages of which are given, 28 were not over 15 years of
age, of whom but 1 died (3.57 pr. ct.), 18 were between 15 and 25 years
old, of whom 2 died (11.11 pr. ct.), and 41 were older, of whom 8 died
(19.51 pr. ct.).

Of those in whom either the entire tarsus or at least the whole of one
of its great divisions was taken away, the death-rate was, under 15 years
of age, 6.67 pr. ct., over 15 and under 25, 10 pr. ct., and over 25, 27.27
pr. ct.

Of the 6 operations for gunshot injury the subjects of which were all
adults, 1 (Tiling's) resulted in death (16.67 pr. ct.). In 4 of these 6
cases (in which is included the fatal one), an ankle-joint amputation
would otherwise, without doubt, have been performed ; an operation that
for gunshot wound in our late war had a mortality rate of 25.1 pr. ct.

As respects the preservation of life then, excision of the whole tarsus,
or of one of its great divisions, is not much, if any, more dangerous than

1883.]

Conner, Excisions of the Tarsus.

377

an ankle-joint amputation, and not very much more so than a middle
tarsal operation.

It has, moreover, the advantage of permitting, if necessary, of the sub-
sequent removal of the foot, which, in the cases tabulated, was performed
seven times with but a single resulting death. That the disease is very
unlikely to reappear is shown by the fact, that in only 3 cases (Champion's,
Eobert's, and Moreau's) did such recurrence take place. This fact, how-
ever, is not so strange as it may at first seem, as it is in direct accordance
with the recognized law that the more thorough the removal of diseased
bone the less will be the likelihood of a relighting up of the bone inflam-
mation.

By far the most important question of the three proposed is that which
has reference to the functional value of the saved foot. Is its usefulness
likely to be sufficiently great to warrant the taking of a somewhat increased
risk of life, and in subjecting the patient to the necessarily much greater
duration of the period of healing — a period that, though it may be as short
as four weeks (Wakley's), may occupy more than twice as many months
(Socin's), or even half as many years?

In 13 of the 97 cases that did not die, the reports, either because im-
perfect or made soon after the performance of the operation, do not clearly
indicate the end-result. In 10 the operations were failures, subsequent am-
putation being required in 7 of them; in 1 of these 7, however (Homan's),
the healing is stated to have been progressing favourably, the foot having
been removed at the patient's request ; and in another (Watson's), made
out of regard to " the patient's sensitiveness and weakness," the operator
was " chagrined to find that there was no condition which should not have
admitted of sound cicatrization."

In 6 cases I have considered the result as fair, five of the individuals
being able to walk about, but requiring the aid of a cane, and in the sixth
there was considerable motion at the ankle-joint, and the toes were freely
movable, though the woman, two years and a half after the operation,
continued to use a crutch in walking.

Forty -five times the ultimate functional value of the foot was very
good, and twenty-three times more, good : and no small part of the twenty-
three good results might very properly, I think, have been included with
the very good.

Put in figures, we may say that, of the 108 operations, 10.18 pr. ct. re-
sulted fatally (more justly, as has already been stated, 8.33 pr. ct.). Of
• the 95 cases, the end-results of which are known, 10.53 pr. ct. were fail-
ures ; 6.32 pr. ct. left the subjects of them able to walk with a cane or
crutch ; in 24.21 pr. ct. there was, after complete consolidation had taken
place, no pain nor tenderness, little or no limp, and the individuals were
not prevented by the condition of the foot from earning a livelihood ; and
in 47.37 pr. ct. the result was so good that the gait was not a bad one,

378

Conner, Excisions of the Tarsus.

[Oct.

the support of the body was firm, and locomotion was so easy and perfect
that the individuals could, without special fatigue, walk long distances ;
even six leagues a day, if we may believe the report of de Housse's case,
certainly, twelve to fifteen miles a day, as Michel's patient ultimately did.

As respects shape, though it must be changed, ordinarily materially so,
the foot being shortened, broadened, and flattened, still no form of talipes
need be developed if due care be taken to maintain a proper position dur-
ing the period of healing, especially the later part of it.

Surely there was not in any of these sixty-eight cases that " weak,
flabby, and deformed condition" of the foot that Roser would have us
believe is to be expected, even when rapid healing occurs ; and there was
not one of the individuals that did not have " a firm weight-supporting
foot, the serviceableness of which would compare with that of an artificial
foot after a leg amputation." One of Humphry's cases ran about as
though nothing had happened. One of Kappeler's patients, from whom
he had three years previously removed the entire tarsus with the exception
of the posterior part of the os calcis, was able to do full work in a stocking
factory, walk over four miles, in a common shoe, without being tired, and
as rapidly as others, and even dance, though not waltz.

Durand's patient later served thirteen years as a soldier. Beck's was
able to do mountain climbing, and Langenbeck's walked for hours without
limping. Each of my own patients whose cases I have reported in this
paper earns his daily bread by his daily work, the one as a wagon driver,
the other as a baker.

In the case which I reported eight years ago in The American
Journal of the Medical Sciences, the man walked about the city
without any difficulty; and if he did not perform regular work, it was
because of his natural disinclination to do any more than he could help,
and not because of the condition of his foot.

The ankle motions, even in certain of the complete or almost complete
excisions, were to some extent preserved. In Walter's case there was
said to be "perfect usefulness of the joint ;" and one of my own patients
declares that he does not perceive any difference in the movements of the
two ankles. Kappeler reports that in two of his cases the arch of the
foot was preserved, though in a modified form.

In none of the case's was the shortening of the limb so great that it
could not be corrected by a thickened sole ; being in two of the eight
cases in which the amount has been noted one-half inch, in one three-
quarters of an inch, in One one inch, in three one-and-a-half inch, and in
one two-and-a-half inches.

Osseous regeneration to greater or less extent was believed to have
taken place in eight cases (3,' 26, 43, 60, 64, 91, 98, 108).

Examination of the appended table confirms me in the opinion I had
already formed from the cases that had fallen under my own observation,
that the more extensive the removal of bone, the better the ultimate re-

1883.]

Conner, Excisions of the Tarsus.

379

suit. Munch has expressed himself to the same effect ; and Kappeler has
very properly declared that the larger the excision the more it resembles
amputation, as respects the healing.

The very favourable result following many of the most extensive opera-
tions, makes me ready to believe the correctness of the report of Bilguer's
case (which I have not included in the table) of removal, after gunshot
injury, of "nearly all the bones of the foot," in which ultimately the
" officer was enabled to walk and to resume his duties by means of a heel
of double the usual thickness ;" the truth of which Velpeau was evidently
somewhat inclined to doubt.

As respects the method of operating in these tarsal excisions, no defi-
nite rules can be laid down. Ordinarily, a lateral incision or one on each
side, while rendering the removal of the bones more difficult, will give
ultimately the best result, a dorsal cut necessarily dividing the extensor
tendons.

It is, however, very probable, that if the ends of such tendons be at
once united by sutures, most, if not all, of the disadvantages of such sec-
tion will be prevented ; and even if left to make their attachments as best
they may to the soft parts, a very excellent end-result may follow, as in
my own case of removal of the tarsas and metatarsus.

Theoretically, the excision when for caries or necrosis should be made
sub-periosteally, but, practically, it is very doubtful if the preservation of
the periosteum will, in the majority of cases, be of any advantage to the
patient ; as much, if not all, of such retained membrane will usually be
destroyed in the after long-continued suppuration of the wound. Very
great advantage attends the use of the Esmarch bandage ; and quite firm
fixation of the foot and leg must be made.

Immobilization by the application of a plaster-of-Paris dressing, in the
single case in which I made it, did not seem to answer as good a purpose
as the use of the fracture box, or the tin or wire splint.

In determining in any given case whether or not excision should be
performed, the chief, if not the only thing to be taken into consideration,
is the probable ability of the patient to endure the protracted period of
healing.

Very early or quite advanced age is not a positive contra-indication ;
Cooper Forster's patient was but four years old ; Gant's was sixty ; both
recovered with useful feet.

In very unhealthy and much debilitated subjects, amputation will generally
be preferable to excision ; as also in cases of extensive crushing of the foot.

Under other circumstances, as respects the cause of the existing
disability and the general condition of the patient, I cannot but feel that
enough has already been done by English, Continental, and American
surgeons to show that the generally received opinion that extensive tarsal
disease necessitates amputation is an incorrect one, or at least one that re-
quires and should have reconsideration.

380

Mendelson, Renal Circulation during Fever.

[Oct.

Article IV.

On the Renal Circulation during Fever. An Experimental Research
made at the Pathological Institute of the University of Leipzig. To which
was awarded the Cartwright Prize Essay for 1883. 1 By Walter Men-
delson, M.D., of New York.

The object of this research was to determine by experimental methods
the actual condition of the circulation in the kidney during fever.

Heretofore no such experiments have, to our knowledge, been made.
Renal pathology has had to content itself with hypotheses founded on the
general condition of the circulation as it could be observed in more acces-
sible parts of the body, and on the changes occurring in the urine.

It is perhaps natural that from these insufficient methods wrong conclu-
sions have been drawn. Our work, founded on direct experimentation, has
shown the opinion, heretofore prevalent, that the kidney during fever is
in a state of congestion, to be wrong. Instead of being swollen, from its
vessels being distended with blood, it is, on the contrary, small and
shrunken, and in a state of extreme anaemia.

We present in this paper the details of the experiments by which we
arrived at the above results, as well as further conclusions derived there-
from.

The work was done during the months of May, June, and July, 1882,
in the Physiological Institute of the University of Leipzig, where we have
acted under the advice and kind auspices of Professor Cohnheim, who
suggested to us the subject and gave us his counsel as to its details. We
take the opportunity presented to us here, to express to him our thanks
and appreciation for all the facilities so freely offered in carrying on this
research.

We employed for our investigations the instrument invented by Roy
and used by him in studying the functions of the spleen,2 and by him
and Cohnheim together in studying the kidney.3 This instrument, called
the Oncometer or " bulk-measurer" (for description see pages 386, 387,
and 388, Figs. 1 and 2), can be applied to the kidney without, as has been
shown by its inventor, interfering with the functions of the organ, and it
affords at all times an exact index to the condition of its circulation.

Having had thus placed at our disposal a means by which the circulation

1 The Cartwright Prize of $500, open to universal competition, is given every other
year for the best original research presented to a committee appointed by the Alumni
Association of the College of Physicians and Surgeons of New York.

2 C. S. Roy, The Physiology and Pathology of the Spleen. Journ. of Physiol., vol.
iii.

3 Same. On the Mechanism of the Renal Secretion. Proc. of the Cambridge Philos.
Soc, May 23, 1881. Cohnheim and Roy, Untersuchungen iiber die Circulation in den
Nieren. Virchow's Archiv, Bd. lxci. p. 424 (1883).

1883.] Mendelson, Renal Circulation during Fever.

281

could be satisfactorily studied, it next remained to hit upon a method of
producing the fever in the dogs to be used, while they were in that state
of complete immobility during the time the oncometer was in use, which
is absolu ely necessary for success.

As a full comprehension of all the methods used is desirable, in order to
fairly judge the results obtained, they will be detailed at length.

Methods of producing Fever The ordinary means of artificially pro-
ducing fever in animals has been to inject into a vein or under the skin,
pus, or infusions of various organic matters, as hay,1 for instance. Lately,
von Bergmann and Angerer2 have found that the injection of solutions of
pepsin, and of fresh gastric juice into the blood causes a marked rise of
temperature, and although we cannot, from want of sufficient proof being
adduced, agree with the explanation given by the authors, still the fact we
have a number of times confirmed.

The fever produced by these various means has always been in animals
not under the influence of drugs which paralyze the motor or sensory func-
tions. We found that when these functions were profoundly affected the
expected febrile rise of temperature did not ensue, as was illustrated by
the fo lowing experiments : — 3

1 Billroth, Laugenbeck's Archiv, vol. ii. vi. xiii. C. J. "Weber, Berlin, klin. Wocbens.
1864.

2 E. v. Bergmann and J. Angerer. Das Verhaltniss der Fermentintoxicationen zur
Septica?mie. Festschrift zur Feier des 300-jahrigen Bestehens der Universitat zu
"Wurzburo-, 1882. These authors hold that the injected pepsin, gastric juice, etc., have
the power of dissolving the white blood globules, which leads to a coagulation of the
blood, and that all the symptoms, as vomiting, diarrhoea, dyspnoea, etc., are due to
capillary thrombosis of the organs in which these symptoms originate. It is not quite
clear to us whether they regard the fever as due to a prevention of radiation from the
skin on account of the cutaneous capillaries being occluded, but it would almost seem
to follow from their statements. Of the actual occurrence of this general capillary
thrombosis there are no conclusive proofs, and to our mind it seems much more likely
that the symptoms are of nervous origin ; the digestive ferments injected into the blood
producing a disturbance of the central nervous system.

8 Since writing the above, N. Zuntz has published a short article entitled " Zur
Theorie des Fiebers" in the CentralUatt f. cl. med. Wissenschaften, No. 32, August 12,
1882, in which he describes obtaining results in curarized dogs, identical to ours.
Zuntz concludes, rather hastily it seems to us, that the febrile process in general is
due to increased oxidation caused by the irritation of the nerves by pyrogenous agents,
and as the muscles are the chief seat of tissue metamorphosis, consequently — he argues —
when the terminal nerve-plates are paralyzed by curara, the oxidizing powers of the
muscular tissue become paralyzed also, and no fever ensues.

This assumption, however, does not tally with our cases where there was absence of
fever in animals under the influence of morphine, where the nervous supply of the mus-
cles was in nowise affected. Much more investigation, and especially calorimetrical
determinations like those of Senator, Wood, etc., are necessary before such a complex
question, involving so many different factors, can be definitely decided,
i Our own opinion is that the absence of fever is due to some central nervous cause,
but whether inhibitory or irritative in nature we would not venture to say.

382 Mendelson, Renal Circulation during Fever. [Oct.

Experiment No. 2. — Injection of pus after morphine. May 12th, 1882. Dog.
Weight 6500 grams. 10.40 A. M. Temp. 39.3° C. in rectum.

Time. Temp. Remarks.

10.40 A. M. 39.3° C. Injected 0.06 morphine hypod.

10.45 Vomited and defecated. Beginning to grow quiet.

10.50 Losing power in legs ; sinks to floor.

11 38.4 Injected beneath skin of left thigh 25 ec fresh pus,

free of all odour, and containing very few bacteria.
11.15 37.5 Asleep, but easily awakened by any sudden noise.

Covered up.

11.55 36.4 Lying on side ; quiet, but not asleep.

12.30 P.M. 36.3
2 36.4

2.45 36.8 Running about in an uneasv, aimless sort of way.

3.45 37.2
7.45 39.4
May 13th.

9.30 A. M. 40.8 Listless and dejected. No appetite.

11.15 40.6

In this experiment but 0.06 of morphine were injected ; an amount
barely sufficient to put the dog asleep for any length of time, let alone to
produce a deep narcosis, yet the temperature sank from 39.3° to 30.3° in
a little less than two hours, in spite of the fact that a quantity of pus had in
the mean time been injected, — pus which in another dog, not morphinized,
caused a rise of temperature from 36.3° to 39.9° in forty-five minutes.
Nor till nearly nine hours after the purulent injection, and when the effects
of the morphine may be fairly assumed to have passed away, had the tem-
perature risen to its original value. The next morning the dog was de-
jected, ate nothing, and in fact presented all the outward symptoms of
having fever. The temperature was 40.5°, and remained at about that
height during the day, showing that the lack of fever in the beginning
was not due to the pus having lost its fever-producing properties, but to
the action of the morphine upon the system.

Experiment No. 12. — In a healthy dog weighing 5420 grams, and having a
temperature of 39.2° C. at 10.30 A.M., 20 c. c. of hay infusion were injected
into a vein. The infusion was two days old, had no putrid odour, but contained
a large number of bacilli. At 1 P.M. the temperature had risen to 40.6° C.
when 14 c. c. of the same infusion were injected hypodermatically, and the
animal placed in a warm-air chamber, having a temperature of about 20° C.
This last precaution was taken to prevent excessive radiation, the day being
somewhat cool. In the meanwhile the dog had become much dejected, vomited
frequently, or made attempts to do so, and had had several movements from the
bowels. At 2.5 P. M., three hours and thirty-five minutes after the first injec-
tion, the temperature was 41.5° C, a rise of 2.3° C, proving conclusively the
power of this infusion to cause fever. The dog afterward recovered fully.

Experiment No. 13. — Injection of hay-infusion after (morphine and) curara.
June 15th, 1882. Bitch. Weight 4970 grams.

Time. Temp. Eemarks.

9.50 A. M. 39.4° C. Before any operative interference.

10 ...... Injected hypod. 0.02 morph , and after exposing left

kidney for the oncometer, and performing other ne-
cessary operations, injected into vein 3 c. c. of a )
per cent. sol. of curara (which had to be followed at
intervals by more).

1883.] Mendelson, Renal Circulation during Fever. 383

Time. Temp. Remarks.

11.30 A. M Put in warm box (temp, about 30° C.),-and injected

into vein 25 c. c of same hay-infusion that was used
in the experiment just detailed.

11.40 34.4° C.

12.10 P.M. 34.2
12.30 34.2
12.55 34.4

1.25 34.6

1.45 34.7

A small quantity of morphine was given in the beginning to sufficiently
dull the pain of the operation, and the curara administered immediately
before the oncometer was applied to the kidney. During the hour and a
half used in performing the necessary operations (which aside from the
larger one of exposing the kidney, included the minor ones of laying bare
the carotid and inserting a canula for connection with the manometer,
besides preparing a vein for the injection of curara and hay-infusion), the
temperature fell five degrees, part of which was due to the depressing
effects of the morphine and curara, and part to the operation itself. How-
ever, in spite of putting the animal in the most favourable condition to
prevent loss of heat by radiation, the temperature, after injecting the hay
infusion, rose but three-tenths of a degree in two hours.

Experiment No. 19. — Injection of pepsin. June 24th, 1882. Dog. Weight
6000 grams (same dog that was used in Exp. 12, now perfectly recovered).

Time. Temp. Remarks.

10.55 A.M. 39.7° C.

11 ...... Injected into vein 5 grms. pepsin in 50 c. c. water.

(Pepsin did not dissolve completely.)
11.45 40.9 Trembling violently (chill) ; much dejected.

12.20 P. M. 40.8
1 41.4

1.30 42.2 Condition unchanged, but trembling ceased.

6 39 Evidently feels better. Vomited a good deal during

afternoon.

This rapid rise of temperature coincides with the results obtained by
von Bergmann and Angerer.

Experiment No. 22. — Injection of pepsin after chloral. June 28th, 1882.
Dog. Weight 4000 grams.

Time. Temp. Remarks.

10.45 A.M. Injected about 5 grams of chloral in solution into

stomach.

11.15 36.6° C. Dog very drowsy, but not completely narcotized. In-

jected about 3 grms. pepsin in 50 c. c. water (filtered
solution) into vein, and put dog in a warm box at a
temperature of 25°.

11.30 35 5

12 35.2

. 2 P. M Dog so far recovered as to be able to walk about.

4.30 40.2 Tremors; much dejection.

6.15 39.9
June 29th.

10 A. M. 39.9 Dog eats little, and is dejected. (Subsequently recov-

ered entirely, and was used for another experiment.)

1 By an oversight the temperature of the dog before giving the chloral was not taken.

384 Mendelson, Renal Circulation during Fever.

[Oct.

This experiment, like those performed with morphine and curara, shows
that after giving the chloral, a primary fall of temperature took place, which
lasted as long as the effects of the drug were present. Not till the power
of the chloral had sensibly diminished did the pyrogenous agent begin to
assert its presence in the organism, by causing a rise of temperature.

The results of the experiments made to produce fever in narcotized
animals (and more than are here enumerated were performed, and all with
a like result) may therefore be summed up as follows : —

In dogs in which complete motor or sensory paralysis (or both) have
been produced by morphine, chloral, or curara, there is a rapid and
considerable fall of the bodily temperature, even when radiation is to a
great degree prevented by inclosing the animals in a warm-air box. In-
jections into the blood of pyrogenous agents, such as pus, hay-infusion,
and pepsin, fail to cause a rise of temperature as long as the system is
under the effects of the drugs used.

Morphine, chloral, and curara were the only agents employed, but it is
likely that other similar drugs would act in the same way.

Having thus been defeated in our attempts to cause fever in dogs by all
the ordinary means, under the conditions necessary for the experiment, a
number of trials were made with the oncometer in curarized dogs in which
an artificial rise of temperature was produced by keeping them inclosed in
a warm-air chamber. In this way, it is almost needless to say, very high
temperatures (up to 45.5° C), could without difficulty be maintained.
The results, of these experiments will be given further on.

The warm-air chamber consisted simply of a galvanized sheet-iron box
with double sides and bottom, the space between being filled with water
kept hot by Bunsen burners placed beneath. In the walls of the box
were suitable openings for the insertion of thermometers. For a cover, a
double layer of thick felting was found to be the most convenient.

However interesting and instructive the results were obtained with the
artificial thermic fever (if we adopt the nomenclature of H. C. Wood1),
still it might well be objected that as thermic fever is not yet universally
acknowledged to be identical in its nature with infectious and other
fevers, so the deductions drawn from experiments on the former would not
hold good when applied to the latter. Some other method, therefore, had
to be contrived in which the source of the fever should be internal and not
external, and in which the dog should still be insensitive enough to allow
of a successful application of the oncometer.

Wood,2 in his experiments on fever, found that lesions of the brain above
the vaso-motor centre in the medulla, produced no change in the arterial
blood pressure. The thalami optici are supposed to contain the sensory

1 H. C. Wood : Thermic Fever or Sunstroke, Philada. 1872.

2 Same. Fever, a Study in Morbid and Normal Physiology. Smithsonian Contri-
butions to Knowledge, No. 357, Washington, 1880.

1883.] Mendelson, Renal .Circulation during Fever.

385

tracts ; consequently, we thought, destruction of these centres might render
the animal operated on insensible to pain, while its power of reacting to
pyrogenous agents would remain unimpaired.

On consulting Professor C. Ludwig on the feasibility of this plan, he
informed us that he had for some time used this method himself for pro-
ducing immobility in animals in which he was studying the functions of
the various cardiac nerves, and had found that no change, either in the
blood-pressure or the heart's action, occurred after this lesion of the brain.
His mode of operating consists in trephining the skull about five mm. on
either side of the median line, so as to avoid the longitudinal sinus, and at
the point of the greatest cranial convexity, which lies four to five centi-
meters in front of the prominent occipital tubercle. After making a small
slit in the dura mater a blunt glass rod of about two mm. in diameter is
gently pushed down, directly vertically, toward the base of the skull, till it
strikes the bone. The operation, as far as the brain is concerned, is almost
bloodless, and it will be found that in nearly every case the thalamus has
been punctured.

Dogs so operated on are, for all the purposes of the experiment, immo-
bile and insensitive enough to allow of the perfect application of the onco-
meter, and furthermore, it was found that injections of pyrogenous agents
caused the desired rise of temperature. As hitherto our promptest results
had been obtained from injections of pepsin ; this agent was used in these
experiments.

The following experiment is detailed here ; for others, see Experiments
Nos. 24 (p. 403) and 25 (p. 393).

Experiment No. 23. — Injection of pepsin after puncture of right thalamus.
June 28th, 1882. Bitch. Weight 3300 grams.

Time. Temp. Eemarks.
12.30 P. M. 39.8° C. Before any operation.
1.10 Punctured right thalamus.1 Dog's body turned to left,

and has "circus movements" in same direction.

Anaesthesia apparently on both sides, and blindness.

Sensorium much affected.
1.45 39 Injected a filtered solution of 2 grms. pepsin in 40 c. c.

of a 0.6 per cent, solution of NaCl.
2 38.8 Put in warm-air box, temperature about 25°.

3.15 39.7 Lying quietly.

4.30 40.4
5.45 40.3

6.10 40.3 Removed from box. Condition much the same as in

the beginning. Drinks water when offered it, and
notices when called. Head wound dressed with
iodoform.

June 29th. 10.30 A. M. T. 39.8° C. Circus movements not so marked,
though body, when dog stands quietly, is turned to left. Soon sinks on right side

1 It was found that the puncture of one thalamus was sufficient for practical pur-
poses, and that the temperature rose more rapidly and higher than when both thalami
were destroyed.

No. CLXXII Oct. 1883. 25

386

Mendelson, Renal Circulation during Fever.

[Oct.

when left alone. Licks itself, and notices when called. Growls and tries to bite
when handled. No appetite.

July 3d. Dog eats well. Circus movements gone. Some anaesthesia on both
sides, more on right. Wound in scalp healing well.

Unfortunately, no post-mortem examination of the brain was subsequently pos-
sible, as the dog escaped from the yard in which it was confined, and was seen no
more. It may, however, be safely assumed that the thalamus was punctured in
this instance, for in the eight other times, in which this operation was performed,
post-mortem examination showed that the thalamus had* always been reached.

Having thus determined upon a method of producing fever in dogs
which would satisfy the conditions of the research, it next remained to
investigate, by means of the oncometer, the effects of this fever on the cir-
culation of the kidneys.

Description of Apparatus.1 — The oncometer of Roy2 is an ingenious
application to organs in situ of the plethysmograph of Mosso.3 The prin-
ciple of its action, like that of the latter instrument, depends on the expan-
sion of the organ under investigation (due to an increased amount of blood
entering it), displacing a quantity of some surrounding liquid, as oil, equal
in amount to the increase in volume the organ has undergone. By means
of suitable mechanical appliances these variations in bulk, transmitted to
the surrounding liquid, are registered graphically upon the revolving drum
of Ludwig's kymograph.

The Oncometer The oncometer, as constructed for the kidney, con-
sists of an ovoid box of sheet-copper, and is composed of two symmetrical
halves joined by a hinge, a (Fig. 2). Each half is made up of two shells,
b b', the inner fitting accurately into the outer. By means of the nut, c,
which plays upon the tubular screwr, d, soldered into an opening at the
point of greatest convexity of the inner shell, and projecting through a
corresponding opening in the outer shell, the two may be drawrn closely
into apposition with each other. Into the tubular screw, d, fits the double
canula, e, composed of a larger and a smaller tube, as shown in the figure.

At the large canula, f, connection is made with the writing-apparatus,
to be described later, whilst the smaller, g, serves to allow any air-bubbles
to escape that may have remained after the instrument has been filled with
oil. At a point on each half of the box opposite to the hinge there is a
semicircular piece cut out of each edge, which makes a round opening, h,
when the box is closed. This opening is provided with a brass collar, k,
holding the eccentric catch, l, which keeps the instrument shut wrhen in use.
Through this opening the vessels, nerves, and ureter of the kidney pass, as
is shown diagrammatically in Fig. 2 (where M represents the kidney, and n

1 This apparatus may be procured of Mr. Max Schanze, Machinist to the Pathologi-
cal Institute of Leipzig.

2 C. S. Roy, The Physiology and Pathology of the Spleen, Jour, of Physiology, vol.
iii. No. 3.

3 A. Mosso, Von einigen neuen Eigenschaften der Gefasswand, Ludwig's Arbeiten,
1874.

1883.] Mendelson, Renal Circulation during Fever.

387

the vessels, nerves, and ureter), the thick, rounded edge of the brass
collar, k, preventing their being sharply bent or injured in any way.

Fig. 1.

When the oncometer is to be used, both the inner shells are removed by

nd th(

Fig. 2.

unscrewing the nuts, c cf. Around the rim of each, half a centimeter

from the edge, a flat rubber band (shown in section at o o, Fig. 2), upon
which caoutchouc varnish is smeared, is stretched to serve as a washer.

388

Mendelson, Renal Circulation during Fever.

[Oct.

Over the concavity of each of the inner shells a piece of moistened calf's
peritoneum1 is loosely laid, the edges turned over, and pressed against the
varnish on the washers, and the inner shells are then replaced and brought
firmly against the outer ones by the nuts c Cr. Each half of the oncometer
consists now of a separate chamber, bounded on the outside by the copper
shells, and on the inside by the membrane, p Tf (dotted line). These
chambers are next filled full with olive oil, to the exclusion of all air. A
quantity of oil, a little less in amount than it is calculated the kidney will
occupy, is then pressed out by raising the membranes with the fingers
from beneath, whilst the box is so held that the opening for the canulas
is highest. This manoeuvre is repeated for each half in turn. One
opening is closed with a well-fitting cork, x, whilst into the other, the
double canula, having rubber tubes on each of its arms, is inserted. The
canula and tubes are then emptied of the air they contain by pressing the
oil up into them, and are kept closed by spring clamps placed upon the
tubes.

Fig. 3.

The Oncograph. — The writing apparatus for recording graphically the
changes in the bulk of the kidney (or other organs) has been called by
Roy the oncograph. (Fig. 3.)

1 After numerous experiments with other membranes, Eoy found this one to answer
all conditions, it being thin, flexible, impervious to, and unaffected by oil. See Jour-
nal of Physiology, vol. i. p. 454 ; vol. ii. p. 325 ; vol. iii. p. 205, etc.

1883.] Mendelson, Renal Circulation during Fever.

389

Briefly, it consists of a cylinder, A, which by means of the screw, c,
may be firmly held against the flat, annular flange, e, of the frame, d.
Within the cylinder is an exceedingly thin and light piston-head, r, made
of hard rubber, which is connected above with the lever, g, by the jointed
piston-rod, h, passing through the guides, k k'. The lower joint of the
piston-rod consists of a delicate steel wire, whilst the upper and the
lever, g, are of aluminium, in order that their weight shall offer the least
resistance to slight impulses received by the piston-head. Between the
cylinder, a, which receives the oil, and the flange, e, is clamped a piece
of the same membrane used before (shown by the dotted line, n), which
prevents the escape of the oil from between the cylinder and the piston.
Through the brass tube, l, the oil within the cylinder is connected with
that in the oncometer by means of short glass tubes, connected by bits of
rubber tubing.

When the cylinder is to be filled, the piston is pressed down as far as
the membrane will allow it to go, the cock of the tube, m, is opened, and
oil is then allowed to enter from a height through the tube l, the air
escaping through M. When the cylinder is entirely full, a clamp is put
upon the rubber tube connected with L, and the piston pressed downwards
until the lever stands at any desired angle, the surplus oil escaping through
m, the cock of which is then shut. The lever is lengthened by tying to it
a culm of straw pressed flat, and which has a small piece of aluminium,
p, bent and pointed to act as a style, attached to its end by sealing-wax.

Preparation of the Animal. — The dog (animals weighing from five to
seven kilos were commonly used), after having been rendered insensible
or immovable by one of the means already described, was placed upon its
right side, and, after shaving the skin of the left flank,1 an incision ex-
tending from the lower border of the last rib nearly to the crest of the
ilium was made. The muscles and fasciae were then cut through, layer by
layer — any large vessels that bled being ligated, and the larger nerves
being cut — until the line of aponeurotic junction between the sacro-lumbalis
and the oblique and transverse abdominal muscles was reached. This
wras then so incised as to cut the peritoneum as little as possible, and the
kidney, enveloped in its fat, drawn carefully out through the wound, and
its capsule dissected away. All the small vessels that enter the cortex
from the capsule were either tied with fine thread close to the organ,
or closed by tortion. The large renal vessels and ureter at the hilus
were only so far separated from the loose fat and connective tissue that
envelop them as was necessary to allow their free passage into the onco-
meter. Especial care was taken not to wound the fine plexuses of nerves
and lymphatics that surround the renal bloodvessels on all sides.

The kidney having been prepared, the dog was removed to the warm-

As the left kidney lies somewhat lower than the right, it is more accessible.

390

Mendelson, Renal Circulation during Fever.

[Oct.

air box and the oncometer, previously warmed by being placed in hot
water, applied. Great care was taken not to allow any air to enter the
oil chambers, as the presence of even a small quantity, by its rapid expan-
sion with the rise of temperature in the dog, may cause considerable errors
in the interpretation of the traces. To avoid therefore the entrance of
air, the following method was, after trial of others, found satisfactory.

The oncometer was filled pretty full of oil in the beginning, as de-
scribed on page 388, and closed over the kidney. The two halves being
then gently pressed together, and the larger tube of the canula being
open, the superfluous oil flowed out. As soon as enough had escaped to
allow the edges of the two halves to come together, the catch was snapped
and a clamp applied to the tube, which was then connected with the
writing apparatus, whose tube and the tube of the canula were filled to
the top with oil from a pipette before being joined. In this way a con-
tinuous connection between the body of oil in the oncometer and that in
the oncograph was effected. By raising or lowering the dog the two
instruments were next brought on the same level, in order that the column
of oil should exert no pressure, either positive or negative, upon the
kidney.

As tracings of the general arterial pressure were always taken along
with those of the kidney, the left carotid was connected with the register-
ing manometer, the style of the latter being so arranged as to be as nearly
perpendicular as possible beneath that of the oncograph.

Of the two curves thus traced upon the blackened paper of the kymo-
graph, the upper corresponded to the variations occurring in the bulk of
the kidney, and the lower to those in the arterial pressure as measured in
the carotid.

On inspecting Fig. 4, it will be seen that the kidney trace consists of
a series of waves, each wave being made up of a number of wavelets.
The former correspond to the respiratory waves of the pulse, while the
latter are the pulse-waves themselves. The accuracy with which these
are traced forms a good index to the sensitiveness of the apparatus.

As each experiment always extended over a number of hours, it was.
of course, out of the question, and, indeed, unnecessary to take a con-
tinuous tracing of the whole duration, but instead, short tracings were
made, generally at intervals of from five to fifteen minutes. The tem-
perature of the dog, taken in the rectum or vagina, was noted on the
blackened paper at the beginning of each of the sections of which the
whole tracing was finally composed. In this way a very graphic impres-
sion of the results of the experiment was obtained on a space of paper
readily overlooked at once.

It will be observed, on examining Fig. 4, of Experiment No. 8, detailed
below, that the kidney tracing constantly approaches nearer and nearer
to the abscissa, whilst the mean arterial pressure gradually rises, only to

392

Mendelson, Renal Circulation during Fever.

[Oct.

fall again when the temperature reaches a point at which life becomes
impossible.1 With each rise in the bodily temperature, there is a corre-
sponding fall in the kidney trace, until at last the pulsations of the kidney
become so small that the oncograph fails to register them, and the trace,
instead of being made up of a number of curves, now changes to a straight
line. The pulse waves disappear firstj being the smallest, and these are
followed by the respiratory.

The calculation of the amount of diminution in volume which the
kidney undergoes was made as follows : —

At the beginning of the experiment (or at its close, it makes no differ-
ence which), the oncograph was disconnected from the oncometer, and its
tube connected with a graduated burette filled with some of the same oil
used for the other apparatus. Oil from the burette was then allowed to
slowly flow into the oncograph, one cubic centimetre at a time. As the
oil entered, the lever g (Fig. 3) of course rose, its style, p, making an
upright trace upon the blackened paper. After the injection of each cubic
centimeter the drum of the kymograph was allowed to revolve for a couple
of seconds, which caused a horizontal mark, about a couple of millimeters
long, to be made at right angles to the former trace.

Thus, a scale was made, the number of whose divisions corresponded to
the number of cubic centimeters of oil that had entered the writing appa-
ratus. Each division of this scale was then measured, and was found in
this case to be 13 mm.2 The difference between the height of the lever, as
measured from the abscissa, at the beginning and at the end of the experi-
ment, expressed in cubic centimeters of oil, would therefore give the loss
in bulk maintained by the kidney during the course of the experiment.
The diminution of the kidney's bulk, however, is due to the diminished
amount of blood that enters it; therefore, instead of reckoning cubic cen-
timeters of oil, the weight of cubic centimeters of blood must be taken.

The specific gravity of dog's blood, as we determined it, was 1.061 ;
consequently, it was only necessary to substitute this figure for each cubic
centimeter of oil to obtain the loss in weight which the kidney had sus-
tained.

The application of the oncometer, merely to determine the facts regard-
ing changes occurring in the renal circulation during fever, was made in
all ten times (seven with thermic, and three times with pepsin fever),
and every time, without a single exception, it was shown that during
fever a progressive diminution in the volume of the kidney occurs.

Two experiments are given here as examples of this : —

1 This rise and subsequent fall of the arterial pressure correspond to the results
obtained by Senator. See Die Albuminuric im gesunden und kranken Zustande, p.
45. Berlin, 1882.

2 The length of the divisions of the scale will, of course, vary with the length of the
lever.

1883.] Mendel son, Renal Circulation during Fever. 393

Experiment No. 8 (Fig. 4).— Thermic fever. May 25th, 1882. Dog. Weight
5 kilos.

Time. Temp, of dog. Temp, of box. Remarks.

10.30 A.M. 39.4° C Before any operation. Then exposed left

kidney, left carotid, and a vein. Curara,
and artificial respiration 26 to the minute.
Put in box.

11.35

38.2

11.55

38.2

45° C.

12 M.

38.3

12.20 P. M.

38.8

12.30

39.2

12.55

40.2

1.5

40 6

1.20

41 4

1.30

1.40

42.2

1.45

42.4

2.20

44.2

2.35

44.6

2.45

2.55

45.4

3.10

Restless ; received more curara.
Still somewhat restless.

After about every 6th respiration there is a
temporary increase of the blood pressure,
with a corresponding temporary decrease
in the volume of the kidney.

Dog dead. Renal vessels tied, and the organ
removed and weighed ; weight 24.55 grms.
Calculation. — Height of lever at beginning of experiment, mm. 126
" " " » close " " . mm. 2.5

Difference, mm. 123.5
13 mm. on the scale = 1 c.c. oil = 1.061 grm. blood; therefore
123.5 mm. " u " = 9.5 c.c. oil = 10.079 grm. blood ; = what the

kidney lost in weight during the experiment..
24.55 + 10.079 = 34.629 grm. = original weight of kidney.
Loss of weight = 29.08 per cent.

Experiment No. 25 (Fig. 5). — Pepsin fever after destruction of left thalamus.
July 3d, 1882. Dog. Weight 6400 grams.
Time. Temp, of dog. Temp, of box. Remarks.

9 A.M. 39.7° C. Before any operation. Punctured left thala-

mus, then exposed the kidney, and per-
formed the other necessary operations.
Placed in box, merely to prevent excessive
radiation.

Injected into vein about 6 grms. pepsin in

100 c.c. water (filtered solution).
Considerable salivation.

11.45

38.6

11.55

12.10 P. M.

35° C,

12.20

38.2

1.30

38.9

1.55

39.3

2.30

39.8

40.2

3.40

40.5

1 The temperature of the box in all these experiments cannot be taken as the abso-
lute one to which the animals were exposed, as in many cases the cover was left oti
entirely, or very frequently removed for purposes of examination, and consequently
free radiation must have occurred.

394 Mendelson, Renal Circulation during Fever.

[Oct.

1883.]

Men d e l s ON , Renal Circulation during Fever.

395

Time. Temp, of dog. Temp, of box. Remarks.

4.50 P. M. 41.2° C. 28° C. Dog restless; mouth dry; drinks water when

given it. Respiration at times very jerky.
Has spasms of extensor muscles of limbs
and trunk.

5.40 41.9 28

6.10 41.8 28

6.15 41.6

6.20 ... Tied renal vessels, and removed kidney.

Weight 21.2 grms. Dog killed.
Post-mortem Examination. — Left thalamus extensively destroyed. The lower
half of the right thalamus has been punctured in a direction from the median line.
Calculation. — Height of lever at beginning of exp't (temp. 38 6°), mm. 155
" " " " close " (temp. 41.9 ), mm. 105

Difference, mm. 50
13 mm. on the scale = 1 c.c. of oil = 1.061 grms. of blood ; therefore
50 mm. " " " = 3.85 c.c. of oil = 4.08 grms. of blood = what the

kidney lost in weight during the experiment.
4.08 21 .2 = 25.28 grms. = original weight of kidney.
Loss of weight =16.14 per cent.

The following are the estimations of the loss of weight the kidney sus-
tained in different experiments.

Xo. Thermic fever. Pepsin fever.

Experiment Xo. 7, 31.14 per cent.

" " 9, 20.33 "

" " 10, 32.49 "

" " 11, 23.12 "

" " 24, 7.88 percent.

" " 25, 16.14 "

As it could be supposed that this contraction of the renal vessels, caus-
ing the loss in bulk of the kidney, might take place in non-fevering dogs
as well, merely from the irritation due to the presence of the oncometer,
several experiments were made to settle this point. The oncometer was
applied to the kidney and left on for several hours, the bodily temperature
being normal. It was found, however, that the kidney retained its original
volume throughout, but began to contract as soon as fever was afterward
superinduced.

Determination of Cause. — The fact of the kidney's diminished volume
having been thus definitely determined, it now remained to investigate
the causes.

That changes in the volume of the kidney must depend on the amount
of blood contained in its bloodvessels at any one time, becomes evident
when we consider that the kidney is an organ which, outside of these ves-
sels, contains no contractile elements.

• Variations in the volume of blood caused by changes in the calibre of
the renal capillaries may take place either from a central irritation, a
peripheral irritation, or a combination of the two.

Peripheral Irritation — Roy and Cohnheim have shown that when the
nerves of the kidney are intact a contraction of the organ, consentaneous

396

Mendelsox, Renal Circulation during Fever.

[Oct.

with the rise of the general arterial pressure, occurs when a peripheral
stimulus is applied to any part of the body. This reaction may be used
as a test to determine whether the connections between the nervous
centres and the kidney have been completely severed or not.

Section of the nerve trunks supplying the kidney is always a tedious
operation, and at best an uncertain one, as the origin and course of the
nerves are subject to considerable variation.1 We found it better, instead
of severing the main branches, to carefully tear away with a pair of deli-
cate forceps, all the nerves that could be seen entering at the hilus, and
as these surround the vessels in a close plexus, considerable care is requi-
site to clean them away thoroughly. The ureter was divided about an
inch from the hilus, in order to cut off all nerves entering on it.

It was found in the majority of cases, that after this operation had been
carefully done, the kidney no longer, or but slightly reacted to peripheral
stimulation, showing conclusively that all, or by far the greater number
of renal nerves must have been divided. As intra-renal ganglia have not
to our knowledge been discovered, it was a priori to be supposed that after
severance of the nervous connections no change would occur in the kidney
during a rise of temperature. This supposition proved to be correct.

Experiment No . 33 . — Kidney enervated. Thermic fever. July 20th, 1882.
Dog. Weight 5400 grains.

Time. Temp, of dog. Temp, of box. Remarks.

10.30 A.M. 39.5° C. Before operation. Gave morphine 0.04 hypo.

and later curara. Artificial respiration.
Kidney exposed and enervated of all
visible nerves, and ureter cut.

12 36.9 Faradic stimulation of sciatic causes rise in

arterial pressure, but kidney remaius al-
most unaffected.

12.45 P. M. 38 45
1 38.9 52

1.15 39.7 42

1.55 40.7 42

2.5 41.6 ... Dog killed.

On inspecting Fig. 6, corresponding to this experiment, it will be seen
that after a faradic stimulation of the sciatic the arterial pressure be-
came increased, while the kidney underwent but a very slight enlarge-
ment. At first sight it might be supposed that the kidney trace ought to
follow in parallel lines that of the arterial pressure, rising and falling with
it, but that it does not do so, but remains, on the whole, nearly parallel to
the abscissa, may be explained by the fact that when the renal nerves
are severed, the capillaries, owing to lack of tonus, at once dilate nearly
to their maximum capacity, and being thenceforth always in a state of en-
gorgement, cannot be filled much fuller, even when a general rise of arte-

1 Ft. Nollner, Die Anatomie des Splanchnicus und der Nierennerven beim Hunde.
Eckhard's Beitrage zur Anatomie und Physiologie. Giessen, 1S69.

rial pressure occurs. That the arterial tonus is much diminished, if not
gone entirely, is confirmed by the separate pulse-waves of enervated kid-
neys being usually larger than of those in which the nerves have been left
intact.

It was several times observed that strong faradic stimulations, applied
to the sciatic immediately after the enervation, failed to produce any

398

Mendelson, Renal Circulation during Fever. [Oct.

contraction of the kidney, whereas, after an hour or two, when these stimu-
lations were reapplied, a slight reaction of the organ was registered by the
tracing; but the degree of this reaction was always very small compared to
that of uninjured kidneys. This phenomenon may be explained by assum-
ing that after the operation those nerves that had escaped being cut must,
at all events, have been considerably bruised, and thus for a time rendered
unfit for conducting purposes. After a period of rest, however, they re-
covered their function, allowing the reflex effects of a peripheral stimulus
to reach the kidney, and to cause there a contraction of those few vessels,
the conduction of whose nervous supply had not been permanently destroyed.
So fine and almost invisible are the nerves that enter the kidney on the
sheaths of the vessels that whilst it is possible to sever by far the greater
number of them, some few are almost sure to escape in every case. Prac-
tically, however, the presence of these remaining fibres does not interfere
with the interpretation of the result of the experiment, for the difference
between the tracing of the non-enervated kidney of a fevering dog and
the enervated organ is too striking not to be at once apparent.

Whilst the former, as we have seen, approaches constantly the abscissa
as the temperature rises, the mean curve of the latter pursues an almost
parallel course.

Spinal Cord. — Still another method of severing the connection between
kidney and brain remained, and that was to perform section of the cord,
but, as was expected in the beginning, the results obtained in this manner
were not so satisfactory as those afforded by the direct enervation. The
possible connections between brain and kidney by way of the sympathetic
are so numerous and complicated1 that, no matter at what level the cord is
cut, one can never be sure of being above the point of exit of all the sup-
plying , nerve branches. Section of the cord, even when performed low
down, has also the disadvantage that the arterial pressure subsequently sinks
to a very low point, and that a rapid fall of temperature occurs. In conse-
quence the dogs stand the operation badly ; death occurring two or three
hours after.

In every case where section of the cord was made, however, results tal-
lying closely with those cases of enervation where it could be fairly assumed
that a certain number of nerves had escaped, were obtained. It was found
that the kidney tracing remained almost uninfluenced by the rise of bodily
temperature, and that, although the kidney could be made to slightly con-
tract by applying a very powerful faradic stimulus directly to a bared
nerve, as the median or sciatic, yet this reaction was almost nil when com-
pared to that which takes place when the cord is intact.

Local Fever — Further determinations regarding the central or periphe-
ral origin of the renal contraction were made by causing a local fever, as

1 Nollner, op. cit.

1883.] Mendel son, Renal Circulation during Fever.

399

it were, in the brain, whilst the kidney and the rest of the body remained
of normal temperature. This was done by means of the apparatus invented
by Goldstein for studying the dyspnoea of fever.1

This apparatus (see Fig. 3, No. 2) consists of a brass water-jacket
fitting pretty closely around the carotid, and through which hot or cold
water can be made to flow from vessels connected with it by rubber
tubes. In order to insure a more prompt heating of the brain each caro-
tid was provided with such a jacket, and the water was made to pass
through both simultaneously. Between the hot jackets and the surround-
ing tissues several layers of thick, dry filter paper were laid which were
found sufficient to prevent the vagus and other nerves being irritated by
the heat.

Hot water of a measured temperature was allowed to run through for a
certain length of time, a mark being made on the trace at the beginning
and at the end. After the hot, some cold water was run through the
brass jackets to cool them.

It was noted in all the experiments that in a few seconds after the hot
water had entered the jackets the tracing registered a contraction of the
kidney, while the general arterial pressure gradually rose. There was a
latent period of varying length before the contractions began, and they
lasted a short time after the hot water had been shut off and cold had
been turned on, the kidney resuming then quite, or very nearly, its origi-
nal volume and the blood pressure falling to its former height.

This reaction to a direct central irritation appeared so constantly and
with such promptness that no misinterpretation of its significance was very
well possible.

It may be remarked, by way of parenthesis, that we were fully able to
corroborate Goldstein's observations regarding the dyspnoea that occurs
during the temporary heating of the brain by hot blood, inasmuch as the
appearance of rapid respiratory movements, becoming in some cases almost
convulsive in nature, were regularly noticed every time the blood in the
carotids was heated.

It might perhaps be urged that the change in the kidney was due re-
flexly to the sensation of asphyxia present, as shown by the dyspnoea, and
of which the violent attempts at respiration were the exponent. That this
however was not the cause, was proved by the arterial pressure remaining
unchanged. Ordinarily, when asphyxia is produced, the general arterial
pressure begins to rise a few seconds before the kidney begins to con-
tract.

Taking the results of all the experiments made into consideration', we
think it justifiable to draw the following conclusion : —

1 Ueber Warmedyspnoe, L. Goldstein. Arbeiten aus dem physiologiscben Laborato-
rium der Wiirzbur&er Hochschule. A. Fick, 1872.

400

Mendelson, Renal Circulation during Fever.

[Oct.

The decrease in the bulk of the kidney during fever is due to a contraction
of its vessels which, in all probability, is the result of a stimulus conveyed
to them from the central nervous system ; the stimulus being the conse-
quence o f irritation of the central vaso-motor centres by the abnormally hot
blood circulating through them during fever.

We have purposely said " in all probability," for Mosso,1 in his investiga-
tions into the properties of the walls of the bloodvessels, has found that a
contraction or dilatation of the vessels of extirpated kidneys takes place
according as certain drugs, such as atropine, nicotine, etc. etc., are added
to the blood with which these kidneys are fed. Still, however instructive
these results may be from a purely physiological point of view regarding
the vessels only, and not the kidney as a whole, they should hardly be
considered as having too much weight when applied to the results of this
research, because the kidney as it exists and functionates in the body of a
living animal is, after all, a thing very different from one extirpated, even
though the latter be kept, so to speak, alive for days, as in Mosso's expe-
riment, by maintaining an artificial circulation through it. From this
reason we refrained from repeating Mosso's experiments, and using hot
blood, considering that no matter what the results might be they would
be of little value in this case, in either proving or disproving the central
origin of the vascular contraction.

General Conclusions — From the experiments made we have proved : —

1. That in dogs with fever the kidney undergoes a diminution in its
bulk.

2. That this diminution is due to a contraction of the walls of the
bloodvessels ; and,

3. That it is constant and progressive, being proportionate to the in-
tensity of the fever.

4. That it is in all probability the result of a nervous stimulus, origi-
nating in the central (cerebral) nervous system from the irritation of
abnormally hot blood circulating there.

From the intimate relations existing between the arterial pressure and
the secretion of the urine, it will at once be evident that many of the
changes occurring in the latter during fever may be readily explained by
considering the above-named facts. Thus the decrease in the amount of
urine secreted by fever patients, which has heretofore been ascribed to the
increased loss of water through the lungs and skin (and which may amount
to one-half,2 or even a third,3 of that normally secreted), becomes all the
more explicable when the marked contraction is considered, which we have
here shown that the renal vessels undergo during fever. For in this case

1 A. Mosso. Von einigen neuen Eigenschaften der Gefasswand, Ludwig's Arbeiten,
1874.

2 Cohnlieim, Allgemeine Pathologie, vol. ii. p. 568, 2d ed. Berlin, 1882.

3 Senator, Untersuchungen ii. d. fieberhaften Process, etc., p. 123. Berlin, 1873.

1883.] Mendelson, Renal Circulation during Fever. 401

it is immaterial whether we accept the theory of Ludwig and his pupils,
that the amount of urine secreted is dependent on the height of the arterial
pressure in the kidney, or that of Heidenhain, that it is due to the rapidity
of the blood-current in the renal vessels. In either case the great con-
traction of the kidneys' vessels would produce both a diminished blood-
pressure and a retarded current within the organ, and hence a lessened
secretion of urine.

The occurrence of albuminuria, such a constant symptom in nearly all
high fevers, becomes readily understood when we bear in mind the ex-
treme anaemia which we have seen affects the kidney during a hyperpyrexia.
For nearly all authorities are now agreed that albuminuria is due to the
glomerulal epithelium, in consequence of being insufficiently nourished with
arterial blood, losing its function of retaining within the vessels the albu-
minous portions of the blood plasma.1 The extreme sensitiveness of the
renal epithelium generally to anaemia, whether partial or complete, has
been shown by many observers,2 and it is not surprising therefore, that in
consequence of the prolonged and marked anaemia in the kidneys of fever-
ing individuals, the epithelium should be so profoundly affected as to seri-
ously impair its function, and allow it to become permeable to albumen.

It must be remembered that the foregoing experiments relate to fevers
which, however high, were but of some hours' duration, and which would
therefore come under the head of acute. It may not be out of place, how-
ever, to call attention to the fact that even in those cases of excessively
high temperature, one example of which is recorded in Experiment No. 8,
p. 393, where toward the close, when death was imminent, and it is probable
that a general relaxation of all the vital functions was occurring, as is shown
by the irregular and feeble action of the heart, and the presence of the
marked Traube-Hering curves (Fig. 4, toward the end, at T. 42.4°),
still, even in these instances, we say, the kidney remains in a state of
complete contraction to the last. We point to this as having some analogy,
perhaps, to cases of chronic fever, where what the temperature fails to
attain by intensity, it makes up by quantity and duration ; and that even
in chronic fever the condition of the kidney, as regards its circulation,
may possibly not be different to that in acute attacks. This is but a sur-
mise which would need the test of further experiment to prove or refute.

Many other interesting questions to be solved in this connection present
themselves. Thus, the actual measurement of the urine during an experi-
mental fever to determine the mutual relations between the amounts
secreted, the temperature, and the degree of contraction of the kidney.

1 R. Heidenhain, Hermann's Handbuch der Physiologic, vol. v. p. 371, 1881. Cohn-
heim, Aligemeine Pathologie, 2d ed., vol. ii. p. 321, 1882.

3 Max Hermann, Sitzgsber. d. Wiener Acad. Math, pbys., CI. lxv., 1861. R. Over-
beck, same, lxvii., 1863. M. Litten, Untersuchungen iiber den haemorrhagischen In-
farct. Berlin, 1879 ; and others.

No. CLXXII Oct. 1883. 26

402 Mendelsox, Renal Circulation during Fever. [Oct.

Then the relation between the renal circulation and the cutaneous. All
these and many more require to be investigated before our knowledge
of the renal circulation during fever will be in any sense complete.
Incomplete in many ways as the author feels this research to be, he
offers it as the first contribution toward the founding of an understanding
of the renal pathology of fever based on experimental investigation,
hoping it may be but the beginning of a series which will clear up this
most important subject. For at present we have been groping in the
dark, forced to content ourselves with theories based on analogies, and
having actually no positive data based on experiment on which to found
our views.

Appendix — Although not strictly belonging here, we think it well to
record the following observations noted in the course of the experiments : —

In a number of cases it was found that the arterial pressure rose with
the increasing bodily temperature of the dog, a diminution occurring when
the temperature had risen to a point incompatible witli life, and when a
general state of collapse had begun.1 If, after the arterial pressure had
risen in consequence of fever, the dog was cooled off, not only did the
blood-pressure sink again, but the kidney increased in volume.

The following are some tables giving the amount of arterial pressure at
different temperatures.

Experiment No. 8. — Thermic fever. May 25th, 1882.

Time.

Temp, of dog.

Arterial pres

sure.

Temp, of box

12.20

38.8° C.

104 rum. of II nr.

46° C.

12.30

39.2

104

((

12.55

40.2

112

1.0

40.6

114

1 1

1.15

41.4

116

t c

1.30

116

i 1

1.45

42.4

130

1 1

42.4

136

t c

1 1

2.7

43.3

140

( i

1 i

2.15

120

2.20

44.2

112

2.28

44.4

3.10 Dog died.

On inspecting Fig. 4, of Experiment No. 8, it will be seen that the
Traube-Hering waves become very marked, and the individual heart-beats
very small and frequent as the temperature approaches lethal limits,
though the mean arterial pressure does not begin to fall until some time
after both these phenomena have put in their appearance. It is highest
at 42.4° C. (136 mm. of mercury), and then rapidly falls, being twenty
minutes after, at the time of death, but 80 mm., the temperature being
then 44.4°.

1 Senator, Die Albuminurie im gesunden und kranken Zustande, p. 45. Berlin,
1882. See, also, Paschutin, Ludwig's Arbeiten, 1873, p. 229, and Zadek, Zeitschrift
fur klinische Medicin, vol. ii. p. 509.

1883.] Mend el sox, Renal Circulation during Fever.

403

Experiment No. 9. — Thermic fever. June 8th, 1882.

Time.

Temp, of dog.

Arterial pressure.

Temp, of box.

37.8° C.

112

mm.

ofHg.

1.40

38.5

100

48° C.

39.5

110

i t

2.16

40.2

120

2.25

40.8

130

i t

i i

2.40

41.8

144

2.50

172

3.10

41.1

134

< c

30 ( Box

3.15

140

25 < cooled

3.25

40.6

148

i i

24 ( off.

3.30 Dog died from hemorrhage from the carotid.

In Experiment No. 9 a continuous rise of arterial pressure, going hand
in hand with the increased bodily temperature, took place until the former
registered 172 mm. at 42° C. The box being then cooled by allowing
cold water to flow through it, the temperature of the dog fell, and with it
the blood pressure ; the kidney increasing in volume at the same time.

Experiment No. 24. — Pepsin fever. June 30th, 1882.

Time.

Temp, of dog.

Arterial pressure.

Eespirat

11.15

36.9° C.

120 mm. of Ho-.

12.30

37.5

134

1.15

37.9

134

1 1

1.30

38.3

138

i i

2.20

38.8

138

2.52

39.2

156

3.20

39.6

156

4.15

156

4.30

40.2

158

5.30

40.5

160

1 1

130

6.5

40.5

140

< i

180

6.30

40.1

160

i i

6.40

160

6.50

Dog killed.

In Experiment No. 24 a continuous rise of arterial pressure took place
to the end, when the dog was killed, the temperature being 40° C, and
the arterial pressure 160 mm.

Experiment No. 25-. — Pepsin fever. July 3d, 1882.

Time.

Temp, of dog.

Arterial presssure.

11.45

88.6° C.

124 mm. of Ho-

12.20

38.2

108 " "

38.7

116 " "

1.55

39.3

118 " "

40.2

126 " "

3.40

40.5

120 " "

4.50

41.2

140 " "

5.10

41.7

136 " "

5.55

41.9

120 " "

6.10

41.8*

104 " "

6.20

Dog killed.

Here the pressure increased till it was 140 mm. at 41.2° when it began
to decline, the temperature still rising. At 41.8° the dog was killed, it
having then sunk to 104 mm.

404 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

Article V.

Calculous and other Affections of the Pancreatic Ducts.' By
George Woodruff Johnston, A.M., M.D., Senior Assistant House Sur-
geon in the Woman's Hospital, New York City : late House Surgeon in the
Hospital of the University of Pennsylvania, Philadelphia.

The earliest writer who mentions the subject of Pancreatic Calculi is
Regnero de Graaf, who wrote in 1671. Since then instances have been
met with from time to time, and recorded with more or less accuracy by
writers both in Europe and in this country, the most recent being a case
under the charge of Dr. William Pepper, at the Hospital of the University
of Pennsylvania, in 1880. Altogether we have been able to collect thirty-
jive cases in which, upon post-mortem examination, stony concretions were
found in the pancreas. We cannot but believe that calculi are present
in the pancreas far oftener than is supposed, and we can only attribute the
paucity of medical literature upon the subject to the inexperience or care-
lessness of the diagnostician or pathologist.

In spite of the many difficulties which always attend the efforts of a col-
laborator, we have succeeded, we think, in obtaining a fair amount of
material upon this subject, and we have endeavoured in these " Extracts"
to summarize as much as possible the results of our work upon the patho-
logical anatomy and symptomatology of calculous and a few allied affections
of the pancreatic ducts.

I, Pathology and Morbid Anatomy.

1. Varieties of Calculous Concretions found within the Pancreas. —
Before proceeding to a minute description of the calculous formations
having their origin within the pancreas, it is well at the outset to refer
briefly to the varieties into which such formations can be classed, and to
mention —

a. Free concretions,

b. Calculous incrustations of the duct walls, and

c. "Acne pancreatica,"

as three general heads, under one or the other of which, all the in-
stances of pancreatic calculi, contained in the reported cases, can easily
be grouped. By far the greater number of stony formations observed be-
long to the class of free concretions; but the other two conditions, though
rare, have been sufficiently well described to render the distinctions be-
tween the classes clear.

a. Free Concretions It is difficult to give any generalization based

upon the observed cases of free concretions, as the older writers adopted

1 Extracts from Inaugural Thesis, University of Pennsylvania, 1882.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 405

the most arbitrary standards of comparison, and as the reports of later
authors are to a great extent incomplete. We have attempted to record,
in the form of a table, all the instances which it has been possible to collect,
in such manner as will most clearly present their many differences and
peculiarities to the eye of the reader. (See table, pp. 406 and 407.)

b. Calculous Incrustations of Duct Walls. — It occasionally happens
that the inorganic constituents of the pancreatic juice, instead of being
precipitated in the form of a free concretion, crystallize upon the walls of
the ducts.1 Calculous incrustations are thus formed, which occur as single
points, or plates, or else layers covering the whole duct wall.2 The origin
of the two hollow concretions, described by Henry and Matani, can pos-
sibly be explained in this way,3 although that mentioned by the latter
seems to be more of the nature of a free concretion, and has been con-
sidered as such. And yet both were large, adherent to the interior of the
pancreas, were hollow, and contained within their cavities a fluid (in the
one case milky- white, in the other green), in which small granular con-
cretions were suspended.

It is well known that one of the changes which occur in the walls of
the so-called kyste confirm^ is a chalky precipitation, sometimes so ex-
tensive as to cover its whole internal surface.4 In one of the cases re-
ported by Recklinghausen, the cyst found in the pancreas was beyond
question the result of the complete occlusion of the duct of Wirsung (by
a calculus), and its subsequent dilatation. The contents of this cyst
were made up in great part of altered pancreatic secretion, and its walls
were studded in some places with thick white plates ; in others with
grayish layers, which glistened like mother-of-pearl ; while in others still
they were covered only by a thin film.5 It seems to us that this descrip-
tion agrees exactly with that already given of lime incrustations upon the
inner wall of the pancreatic ducts, and it does not appear unlikely that we
have here an example of such an incrustation formed simultaneously with
the production of the calculus, and before any dilatation of the duct

1 Klebs, HandbuchderPatholog. Anat., Berlin, 1876. Pankreassteine. 1 Bd., s. 544.

Delafield, Handbook of Post-mortem Examinations and of Morbid Anatomy, New

York, 1872 : The Pancreatic Ducts, p. 203.

2 Klebs, ibid.

3 Matani, Naturen genees-kundige Bibliotheek — door Eduard Sandifort, Graven-
hage, 1765 : Waarneeming van Antony Matani, over eene steenagtige samengroejing van
het alvleesch, in bet lyk van een' menscbe gevonden ; or, Gottingiscbe Anzeigen von
Gelebrten sachen. No. 10,1765. Antonii Matani observatio de lapidea pancreatis con-

cr'etione in bumano cadavere reperta Henry, Journal de cbemie medicale, iv.

serie, Paris, 1855 : Recbercbes analytiques sur une concretion particuliere du Pan-
creas, tome i. p. 273 ; or, France medicale et pharmaceutique, 3e Annee, Paris, 1856 :
Sur l°,s concretions que presente le pancreas, No. 6, p. 42 Klebs, ibid.

4 Klebs, op. cit. s. 517.

5 Recklinghausen, Virchow's Arcbiv, Berlin, 1864: Auserlerne pathologiscb-ana_
tomische Beobachtungen, I. Drei Falle von Diabetes Mellitus, a. 30 Bd., s. 360.

(

406 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 407

408 Johnstox, Calculous Affections of the Pancreatic Ducts. [Oct.

occurred. If tliis is so, mam' of the incrustations found upon the inner
wall of pancreatic retention cysts are the result of the precipitation of the
inorganic constituents of the secretion upon the duct walls prior to their
dilatation, and therefore should not be ascribed to the later changes oc-
curring in the cystic walls, nor be compared to the results of a prolonged
endo-arteritis.1

c. Acne Pancreatica The condition, sometimes met with in the

pancreas, described by the pathologist Klebs, and called by him Acne
Pancreatica, seems to have almost entirely escaped the notice of former
investigators,2 and Klebs himself fails to mention it in his article upon
pancreatic concretions.3 The pathological process involved consisted in
a change of the normal pancreatic secretion into a fatty, chalky pap.4 In
the only case observed with any care, the exterior of the gland was
covered by large light-yellow spots, which, like the acini, occupied a
certain depth, and consisted of a thick, smeary, butter-like substance
containing fat. The pancreatic duct was dilated and filled, as were the
accessory ducts, with a pap-like mass, which contained pus elements and
light particles of hardened protein.5 Yellow spots similar to those above
referred to, and having the appearance of blisters, were found by Klebs
upon the surface of an enlarged pancreas. It is believed that these were
cysts formed by the dilatation of the smaller branch ducts, and the clear or
clouded semifluid mass which they contained was found to be compo.-ed
partly of fat-globules, and partly of some cretaceous material. These
spots may easily be mistaken for abscesses ; for those small cysts which
are only occasionally present in the acini, and are of no pathological
importance ; and, finally, for the small spots (from which chalk or tufts
of fat-crystals can be expressed) found in a gland which has been the
seat of chronic pancreatitis from obstruction of the portal vein.

Only a few other cases have been met with which seem to us illustra-
tive of the condition just described, viz., acne pancreatica. In them either
the pancreatic ducts were found full of a chalky powder,6 of an earthy,
doughy substance,7 or else the whole gland was converted into a tophaceous

1 Klebs, op. cit. s. 547.

2 Klebs, op. cit. s. 547 Gendrin, Histoire Anatomique des Inflammations, Paris,

1826 : Pancreatites chroniques, tome ii. p. 263.

3 Klebs, op. cit. s. 541. 4 Gendrin, ibid.

5 Virchow, Verhandlungen der med. physik. Gesellschaft zu Wurzburg, 1S52 : Zur

pathologisch-anatomischen Casuistik, 4, III. Bd., s. 366, cf. II. Bd.,s.53 Klebs, op.

cit. s. 517 Friedreich, Ziemssen's Encyclopedia of Medicine. New York, 1878 :

Diseases of the Pancreas, Cysts, vol. viii. p. 615.

6 Wilson, Medico-Cbirurgical Transactions, London, 1812 : An account of a case of
extensive disease of the pancreas, vol. xxv. p. 42.

7 Schmitt, Zweifelhafte Schwanger, Wien, 1818 Klebs, op. cit. s. 517 Cornil

et Ranvier, d'Histologie Pathologique, Paris, 1869-1873 : Kystes, t. ii. p. 971 Cornil

and Ranvier, Manual of Pathological Histology, translated by Shakespeare and Simes,
Phila. 1880 : Cysts, p. 581.

1883.]

Johnston, Calculous Affections of the Pancreatic Ducts.

409

or calculous mass.1 It may be here remarked that the chemical composi-
tion of such deposits differs in no way from that of free concretions.

The cause of the formation of chalky masses or concretions in the pan-
creatic ducts, or in the small retention cysts above described, is without
doubt either a chemical alteration, brought about in the secretion of the
gland through contact with the inflamed duct walls, or else an obstruction
offered to the free outflow of the secretion by a local interstitial inflamma-
tory thickening, or a catarrhal swelling ofthe lining membrane of the duct
of Wirsung, or of any of the accessory ducts. The question of causation
will, however, be dwelt upon at greater length in a later section.

2. Location of Calculous Deposits — The seat of the various concre-
tion? found within the pancreas can, we believe, be most clearly shown
by the subjoined analysis. It may be mentioned, however, thaty in the
only instance of calculous incrustation of the duct wall in which the seat
of this incrustation is specified, the part of the duct of Wirsung situated
midway in the gland was alone affected. With regard to the condition
spoken of as acne pancreatica, a sufficiently detailed description has been
already given. We will proceed then to the remaining class, viz., Free
Concretions.

Free Concretions.

Seat.

No. of
instance*.

I. Found in duct of Wirsung only

f
\

Exit

Middle

Tail

Total

3
1

II. Found in branch ducts and in

(
i

Exit

Middle

Tail

Total .

"i
l

7
2

Total

IV Found in abscess in pancreas .

Total

■ V. Found in cyst of pancreas . .

Head

(
<
I

In abscess in right lumbar re-
in peritoneal cavity . . . .

1
1

1 Meckel, Koreff, Dissertatio inaug. med. sist. tbeoret. consid. icteri. Halse Magd.,
1759, § 12. p. 16.

410 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

3. Mode of Origin of Pancreatic Concretions — Although the origin
of pancreatic concretions depends upon some special functional or struc-
tural alteration in or about the gland, yet we must consider these, in some
cases, as the mere local manifestations of some general morbid condition.
Disregarding the study of these general conditions, it will be necessary in
the present section to refer to such local alterations only as are immedi-
ately connected with the production and development of these concretions.
For the sake of clearness we will divide these alterations into two classes,
namely : Changes in the gland itself, or in the chemical composition of its
secretion ; and Changes in the structure or relation of the surrounding
tissues or organs.

Among the many modifications, both functional and structural, of which
the pancreas is the seat, those only are directly connected with the forma-
tion of calculi which tend to prevent the free outflow of the pancreatic
juice. A morbid change in any part of the gland structure,1 especially at
its head ;2 a mucus plug,3 or an already formed calculus lodged in the
duct of YVirsung or any of the larger ducts ; a catarrhal4 or chronic inflam-
matory condition with thickening of the same ;5 an interstitial inflamma-
tion with hyperplasia of connective tissue ;6 or a biliary calculus which
has found its way into the pancreatic duct ;7 are some of the many causes
which go far to explain the origin of pancreatic calculi. The conditions

1 Rokitansky, A Manual of Pathological Anatomy, Syd. Soc, London, 1849 : Ab-
normities of the different duets and their contents, vol. ii. § 2, p. 180 Portal,

Cours d'anat. med. Paris, 1803 ; Pancreas engorge par des concretions pieurreuses,

t. v. p. 356 Salmade, Recueil periodique de la Societe de Medecine de Paris, 1797-98:

L'observation a l'histoire des anevrismes, tome iii. p. 454 Dufresne, Traite de

l'affection calculeuse du foie et du pancreas, Paris, 1851: Article deuxieme, p. 494

Schupman, Hufeland's Journal, 1841, iii. Geschichte einer scirrhbsen Hypertrophic der

Leber und des Pankreas, etc., xcii. Bd., s. 41 Wilson, loc. cit Curnow, Trans.

Path. Soc, London, 1873, 23: Pancreas with numerous calculi in its ducts, vol. xxiv.

p. 136 Muhlbauer, Neue Notizen (von Froriep) Weimer, 1822-1847 Devilliers,

Revue medicale, Decembre, Paris, 1844, tome iii. p. 576 Eller, Collection Acade-

mique, Paris, 1755. Reeherches sur la formation des pierres ou concretions, graval-

leuses dans le corps humain, etc. Partie Etrangere, tome x. p. 85 Sandifort, Ob-

servationes anatomico-pathologica?, Lugd. Batav., 1777. Lib. iii. cap. iv. p. 73

Yirchow, loc. cit.

2 Cawley, London Medical Journal, 1788: A Surgical Case of Diabetes, etc., vol. ix.

part iv. p. 286 ; also Sammlung Auserlerner abhand., Leipsig, 1789, 13 Bd., s. 112

De Graaf, Tractat anat. med. de succi pancreatici natura et usu., Ludg. Batav., 1671,

cap. vii. p. 112 Lieutaud, Hist. Anat. Med., Paris, 1767, liber i. § viii. obs. 1045,

p. 244 Jane way, New York Medical Record, 1872: A case of Calculi of the Pan-
creas, etc., vol. vii. p. 357.

3 Rokitansky, ibid.

4 Curnow, ibid Friedreich, op. cit. p. 615, and Calculi, p. 618 Klebs, op.

cit. s. 547 Parsons, British Medical Journal, 1857, vol. i. p. 475.

5 Recklinghausen, op. cit. b. Concretionen, Ektasien des Ductus Yerbderung des
Parench}7ms des Pankreas.

6 Delafield, op. cit. p. 202 Friedreich, op. cit. p. 615 Parsons, loc. cit.

7 Klebs, op. cit. s. 544 Delafield, op. cit. p. 203.

1883.] Johxstox, Calculous Affections of the Pancreatic Ducts. 411

are varied, it is true ; the effects the same. Let there be an obstruction,
a compression, a complete occlusion of the duct internal to the gland,
and the secretion is dammed back, it accumulates and stagnates when it
should escape, and those conditions most favourable to the precipitation of
its inorganic constituents are all thus furnished. But who can say that
there are not other and more remote causes, in addition to those which
have been already mentioned ? Is compression or complete occlusion of
the ducts necessary ? In atrophy, in morbid softening, especially in fatty
metamorphosis of the gland structure itself, and lastly in scirrhoid indu-
ration, the tissue of the duct becomes involved, the vital contractility is
lost, dilatation ensues with stagnation of the secretion,1 and the same
effect is brought about in an entirely different manner. Instead of dila-
tations and cysts being the result of duct occlusion, by a stone already
formed, they have here become the cause of its formation, and yet it is in
some cases most difficult to say, from a study of pathological appearances,
wThich is the cause, and which the effect.2

It is clear, then, that an obstruction to the free outflow of the pancreatic
secretion will cause retention and accumulation of that fluid within the
ducts of the gland, and thus favour the precipitation of its inorganic con-
stituents. But it is possible that the secretion may become so altered in
the nature or relation of its chemical components, as to bring about a
deposition of its inorganic elements, without any preliminary obstruction
or dilatation of the gland ducts. From a study of the reported cases of
calculous disease of the pancreas, it will be seen that in many instances
calculi have been found within the gland ivhere .no obstruction of the ducts
had existed, such as described in the foregoing and succeeding pages.3 It
now, therefore, remains to be seen what are the changes in the pancreatic
secretion which result in the formation of calculi, and how these changes
are brought about. By a comparison of the chemical constitution of the
normal pancreatic juice with that of pancreatic calculi, one will be struck
by the following facts : In three analyses given of the former, lime,
whether in combination with organic matter, or as free phosphate of lime,

1 Rokitansky, loc. cit.

2 Gould, Catalogue of the Anatomical Museum of the Boston Society for Medical
Improvement, Boston, 1817: Several pancreatic calculi, extensive disease of the pan-
creas, §§ 5T5-6, p. 173 Dufresne, loc. cit.

3 Matani, loc. cit Baillie, The Morbid Anatomy of the Human Body, London,

2d ed. 1812, p. 115, and, London, 1833, Calculi of the Pancreas, p. 222 Elliotson,

The Principles and Practice of Medicine, 2d ed., London, 1816: Diseases of the Pan-

'creas, p. 1009 ; also, Medico-Chirurg. Trans., London, 1833, on The Discharge of Fatty

Matters from the Alimentary Canal and Urinary Passages, vol. xviii. p. 67 Bonetus,

vide Bigsby, loc. cit Gould, op. cit. § 575 Clayton, Medical Times, London,

1819: A case of Calculi of the Pancreas, etc., vol. xx. p. 37.. . ...Henry, loc. cit

McCready, Xew York Journal of Medicine, 1856: A case of Pancreatic Calculi, in

Proceedings of Patholog. Soc. p. 78 Recklinghausen, op. cit. 1, a. p. 360 Cornil

et Ranvier, loc. cit Cornil and Ranvier, trans, loc. cit Schmitt, loc. cit.

412 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

is present only in very small amount, or, as in a fourth analysis, is not
mentioned at all ; whereas, in the various chemical examinations made of
the latter, lime, both as a phosphate and as a carbonate (an element not
found at all in normal pancreatic juice), is present in very large amount,
and forms either the entire calculus,1 or else by far the greatest part of it.2
In addition to the carbonate of lime already mentioned, three other inor-
ganic substances have been found in pancreatic calculi, which, according
to the analysis above referred to, have no place in the pancreatic juice ;
they are the chlorate of sodium,3 carbonate of magnesium,4 and oxalate of
lime.5

In conclusion, let us bear in mind the close analogy which exists
between the pancreas and its kindred salivary glands, in both of which
calculi are found, produced by the same general causes, and followed by
the same effects.6 How does the chemical composition of salivary cal-
culi compare with that of the salivary fluid? It lias been remarked,
that the saliva from which salivary calculi are formed, must be in an
unhealthy state, for, while these concretions consist chiefly of phosphate
of lime, sometimes containing as much as ninety-four per cent, of that
salt, little, if any; is to be found in the normal salivary secretion.7 From
this it is clear, that in true salivary calculi, as in those of pancreatic
origin, the quantity of the salts of lime is much greater than in the fluids
secreted by these glands. The means, by which the pancreatic secretion
is so changed inside the body as to bring about a precipitation of its
inorganic constituents, must still remain a matter of doubt. Various
explanations have been advanced, but none are entirely satisfactory.
It is possible that physiological variations are occasionally present in

1 See in Table of Free Concretions. Baillie, Gould, and Collard: Henry, La France

Med. et Pharm., op. cit. p. 42 Pemberton, on Various Diseases of the Abdominal

Viscera, Richmond, Va., 1830: chap. iv. The Pancreas, p. 64.

2 See in Table of Free Concretions: Clayton, Clark, McCready, Recklinghausen, Cornil

and Ranvier, Janeway, Curnon ; also, Wilson, loc. cit., Rokitansky, loc. cit Gross,

Pathological Anatomy, Phila. 1845: Of the pancreas, chap, xxiv.p.689 Henry,

La France Med. et Pharm., loc. cit. p. 42 Wollaston, see Pemberton and Henry,

ibid.

3 Henry, ibid. 4 Henry, Journal Med. et Pharm., loc. cit.

5 Golding Bird (See Wilks & Moxon, Lectures on Pathological Anatomy, Phila.
1875: Diseases of the Pancreas, Calculi, p. 470).

6 De Graaf, loc. cit., Eller, loc. cit., Matani, loc. cit., Rokitansky, loc. cit., Henry,
La France Med. et. Pharm., loc. cit. ; Friedreich, op. cit. p. 618 ; Wilks & Moxon, loc.

cit., Portal, loc. cit Becourt, Recherches sur le pancreas, Th&>e, Strasbourg, 1830:

Concretions ihor<ganiques, § 5, p. 69 Mondiere, Archives Generates de Medecine,

ii. Serie, Paris, 1836: Recherches pour servir a l'histoire pathologique du pancreas,
tome xii. p. 147 Bigsby, Edinburgh Medical Journal, 1835: Observations on Dis-
eases of the Pancreas, vol. xliv. p. 97 R. D., Dictionnaire de Medecine, Paris, 1841:

Maladies du Pancreas, concretions osseo-pieurreuses, tome xxiii. p. 65.

7 Jones & Sieveking, A Manual of Pathological Anatomy, Phila. 1854: Abnormal
conditions of the pancreas and other salivary glands, p. 532.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 413

the composition of the pancreatic juice, as in the secretion of other
salivary glands, in which occur temporary changes in quantity, in
colour, in consistency, and, as indicated by the taste and alkaline or
acid reaction, in chemical constitution.1 Further, local changes in the
tissue of the secreting portion of the pancreas,2 or in that of its ducts,
may produce such an influence upon the secretion as would lead to the
crystallizing out of its less soluble salts. It has been said that the excess
of phosphate of lime present in calculi is most probably caused by an irri-
tation or inflammation of the mucous membrane lining the ducts,3 and if
this be true, there can be but little doubt that an excess of this phos-
phatic salt, which, as we have seen, is present in nearly all pancreatic
calculi, can be formed in like manner in the ducts of the pancreas.

It seems proper, before leaving this part of our subject, to record in
brief the chemical analyses made of two pancreatic calculi, which, for
obvious reasons, are not to be found in the list of free concretions,4 with
the analyses of two salivary calculi, in order to illustrate the close analogy
which is said to exist between pancreatic and the so-called salivary calculi.

I.5 A pancreatic calculus, wt. 9.06 gm., contained —

Phosphate of lime
Carbonate of lime
- Phosphate of soda
Chlorate of sodium

Animal matter

72.30
18.90
traces

8.80

In 100.00 parts.

2.6 A pancreatic calculus found in canal of Wirsung of an ox con-

tained-

Carbonate of lime
Carbonate of magnesium
Organic matter
Water

91.65
4.15
3.

1.20

3.Y A salivary calculus found

Phosphate of lime
Carbonate of lime
Animal matter .
Oxide of iron .
Magnesium
Waste

In 100.00 parts,

n Steno's duct of a woman contained —

55
15
25
2

traces
3

100 parts.

.! Rokitansky, loc. cit Friedreich, op. cit. p. 618.

2 Recklinghausen, op. cit. i. b.

3 Recklinghausen, ibid Jones & Sieveking, loc. cit.

* Henry, Journal de Chemie Medicale, op. cit. p. 273.

5 Henry, Journal Med. et Pharm., loc. cit.

6 Schulze, Journal liir p. Chemie, xxxix. p. 29: Rap. an de Berzelius, 1848, p. 412:
cf. Henry, ibid.

7 Lassaique,Traite de Chemie, tome ii. p. 614: cf. Henry, ibid.

414 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

4.1 Another salivary calculus contained —

Phosphate of lime ....... 75.

Carbonate of lime ....... 20.

Animal matter ]

Waste j °-

In 100 parts.

The changes in the parts or tissues adjacent to the pancreas, which are
of force in the production of pancreatic calculi, are as numerous and as
varied as those within the gland itself. Yet we will find the same thing
here as there, different causes with like effects ; an obstruction to the free
escape of the pancreatic secretion, a stagnation, an inspissation, and the
formation of a calculus, with all the train of phenomena attending thereon.
And Ave repeat here what has been said in a former section, not only that
calculi, by occluding the pancreatic ducts, cause their dilatation and
the formation of retention cysts ; but that these cysts, whether so formed
or not, favour in their turn the production of calculi,2 and that, therefore,
whatever causes are assigned for the development of retention cysts can
also be considered as secondarily productive of calculi. From a careful
study of the cases of pancreatic calculi which we have collected, we find
no instances in which the production of a concretion has been caused by
compression of the excretory duct through changes outside of the gland ;
nevertheless, since such compression is possible, and may have been over-
looked, we cannot refrain from briefly referring to some of the changes
whereby it may be brought about. Among these may be mentioned
peripancreatic induration and adhesions, especially near the head of the
gland ;3 gall-stones lodged in the common duct and pressing upon the duct
of Wirsung ;4 a cancerous growth in the duodenum ;5 and, finally, changes,
as the result of which the pancreas becomes displaced.6

4. Mode of Escape of Pancreatic Calculi Pancreatic calculi may

escape into the duodenum, accompanied by a paroxysm of pain or colic,
similar to that which attends the passage of biliary or of renal calculi.7
This, instead of being only a probable method of escape,8 is, we believe,
not at all infrequent.9 No case in which a direct observation has been made
can, however, be brought forward in proof of this assertion. As will be

1 Lecannau, Journ. de Pharm. et de Chir., Deceinbre. 1827, p. 626.

2 Virchow, Die Krankhaften Gesdrwiilste, Berlin. 1863, i. Bd., s. 276 Friedreich,

op. cit. p. 615.

3 Hoppe, Virchow's Archiv, 1857, xi. Bd. s. 96: cf. Friedreich, ibid.

4 Engel, Oesterreich med. Jahrbiicher, 1841: xxiii. u. xxiv. Bd.

5 Friedreich, op. cit. pp. 601-15. 6 Engel, ibid; Friedreich, ibid.

7 Friedreich, op. cit. p. 618.

8 Ancelet, Essai Analytique sur l'anatomie pathologique du Pancreas, These, Paris,
1856, tome i. p. 27.

9 Pemberton, loc. cit., Portal, loc. cit.: cf. Dufresne Schupman, loc. cit., Wilson,

loc. cit., Clayton, loc. cit.

1883.] Johns tox, Calculous Affections of the Pancreatic Ducts. 415

discussed in a later section, it is almost impossible to tell from symptoms
whether a pancreatic or biliary calculus is being passed, nor is it easy to
recognize pancreatic concretions in the stools. It is, nevertheless, possible
that in many of the cases which we have collected where, during life, pain,
more or less characteristic, was present, and after death pancreatic, but
no biliary calculi, were found, nature had sought this mode of relief.1

It is known that calculi, acting as foreign bodies within the pancreas,
sometimes give rise to inflammation and ulceration, with subsequent per-
foration of the gland substance. In one reported case perforation was
found at the post-mortem examination, and, although several calculi had
remained in the pancreas, one had escaped into the abdominal cavity.
The patient's death was attended with symptoms denoting internal hem-
orrhage, and a large quantity of coagulated blood was found within the
peritoneal sac.2 In another case, the record of which is rather obscure,
one concretion was found in the pancreas, and several others in an abscess,
situated in the mesentery and opposite the point (the right lumbar region)
where, during life, the patient suffered the greatest pain.3 Although no
lesion of the pancreas was noted, it is not unlikely that the calculi escaped
in the same manner as is mentioned in the last case. A later writer describes
this abscess as peri-pancreatic, but we do not think that the original ac-
count warrants this construction.4

5. Results folloicing the Impaction of Calculi in the Ducts of the
Pancreas.

a. Dilatation of ducts and formation of cysts.
Hemorrhagic cysts.
Hemorrhage into the pancreas.
Dilatation of the ducts of the pancreas, with or without the subsequent
development of cysts, is one of the results which most often follow the
formation of calculi within the gland.5 Yirchow, having in mind the
close analogy (already pointed out) which exists between the pancreas and
the salivary glands of the mouth, has given the name Eanula Pancreatica

1 TVilson, loc. cit Mercklin, Epkeni. nat. cur. decur., Frankfort und Leipsig,

1678: De ingen. calc. in mesen. et pan. repert, Ann. 8, obs. 50, p. 78 Galiati, De

morbus duobus observ. 175S, p. 26 ; or Comment. Bonon, tome iv. p. 31. (Xote. —
It has been impossible to gain access to these two works. The case is quoted by
Sandifort, Mondiere, R. D.,Becourt, and by others.) Elliotson, Med. Chirurg. Trans.,

loc. cit Schupman, loc. cit., Gould, loc. cit., Clayton, loc. cit., Dufresrie, loc. cit.

Clark, London Lancet, Aug. 16, 1851: A case of disease of the pancreas, etc

Fournier, Anc. Journal, tome xlv. p. 119 ; or, more correctly, the journal being better
known under its more recent name, Journal de uiedecine, chirurgie, pharmacie, Paris,
1776, tome xlv. p. 119.

2 Clayton, loc. cit. s Mercklin, ibid.

4 Klebs, op. cit. s. 511.

5 Matani. Baillie, Schupman, Gould, Rokitansky, Dufresne, Clark, Yirchow (Ver-
hand. der Med. physik. iii.), Ancelet, Recklinghausen, Cornil & Ranvier, Janeway,
Curnow, Fournier, Meckel and Delafleld.

416 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

to all dilatations of the pancreatic ducts leading to the formation ot cysts.1
This dilatation of the ducts of the pancreas is due to a distension of their
walls by the mechanical pressure of a retained secretion. The degree of
dilatation, other things being equal, is in direct proportion to the com-
pleteness of the obstruction to the outflow of the pancreatic juice.
Although a calculous concretion is one of the usual and most effective
causes of this obstruction, nevertheless many other changes, both within
and without the gland, undoubtedly produce the same effect. These
alterations have been already briefly referred to,2 but many others exist
which it is not our intention at present to describe.3 It suffices to say,
given an impediment, complete or partial, to the free escape of the pan-
creatic secretion, and the most natural result is a mechanical distension
and dilatation of the ducts behind the obstructed point.

Among the cases of pancreatic calculi collected, dilatation of the main
duct is the result of obstruction the most frequency observed. Generally,
this dilatation represents only an exaggeration of the normal calibre of
the duct, which throughout the greater part of its length is more or less
uniformly dilated.4 If, however, the obstruction is near the point of exit
into the duodenum, and is complete and continued, the dilatation does
not cease here, but the accessory ducts in their turn become enlarged,5
presenting the appearance of diverticula, opening into the duct of Wirsung,
and separated from one another by valvular folds or transverse ridges,
formed by the coats of the ducts, which may be either thickened or at-
tenuated.6 Again, instead of these c'ose-set expansions, there may exist
at intervals single fusiform dilatations.7 It is possible for the accessory
ducts to undergo dilatation without the involvement of the main duct.
Thus they may become closed at their exit by the presence of a calculus,
by local interstitial inflammatory thickening, or by catarrhal swelling of
their lining membrane, with or without the collection of a stringy ca-
tarrhal secretion, the main duct remaining patent throughout. The de-
gree of dilatation, depending as it does upon the conditions already pointed
out, varies considerably in different cases. We have the size of the dilated
main duct compared to that of a quill,8 of the thumb,9 it is said to be

1 Virchow, Die Krankhaften Geschwiilste, loc. cit Parsons, British Medical

Journal, June 15, 1857, vol. i. p. 175.

2 Reference may here be made to the section on the Mode of Origin of Pancreatic
Concretions.

3 Klebs, loc. cit.: Cysts, p. 517 Friedreich, loc. cit.: Cysts, pp. 600-15 Par-
sons, loc. cit Cornil & Ranvier, loc. cit.: Kystes, p. 971 : Trans. Cyst., p. 581.......

Virchow, loc. cit Ancelet, loc. cit.: Kystes, p. 26 Rokitansky, loc. cit Cru-

veilhier, Traite d'anatomie pathologique generale, Paris, 1856 : Kystes Pancieatiques,
tome hi. p. 365.

4 Klebs, op. cit. s. 517 Meckel, Baillie, Gould (op. cit., § 575), Rokitansky,

Virchow, Ancelet, Recklinghausen, and Cornil et Ranvier.

5 Matani, Janeway, and Curnow.

6 Klebs, Rokitansky, Friedreich, and Recklinghausen.

7 Rokitansky. 8 Rokitansky. 9 Matani.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 417

dilated,1 much dilated,2 or prodigiously dilated.3 In one case only was
an accurate measurement made, when the diameter of the duct was found
to be one inch.4

The study of the cysts, or, as the Germans are pleased to call them,
Ektasien, resulting from an extensive and continuous impediment to the
outflow of the pancreatic juice, is an extremely interesting one, and will
be briefly alluded to as one of the many results following the impaction
of concrements. All such cysts found in the pancreas belong purely to
the class of retention cysts, and although in some cases extensive secon-
dary changes seem to render their origin doubtful, yet it is comparatively
easy to exclude pouches beginning outside of the pancreas, even though
pushing aside its glandular tissue, and entering into communication with
its duct, aneurismal dilatations of arteries in the gland, and, finally, cysts
originating from entozoic formation.5

Cysts of the pancreas present many varieties in form and size, have
been studied with some care by pathologists, and are of the utmost syinp-
tomatological importance. Two distinct classes are met with : those which
emanate in an extreme degree of dilatation of the main duct of the pan-
creas, and the small multiple cysts originating from a similar dilatation
of the small ducts within the acini, or of the terminal vesicles of the
gland. The former sometimes attain an immense size, in one case meas-
uring three by four inches ;6 in others compared to the size of a child's
head.7 Their form is generally spherical or oval,8 but varies extensively
in different cases.9

Whereas, in ordinary dilatation of the main or of the accessory ducts of
the pancreas, and also in the first period of the history or development of
a cyst, there is a simple retention of the secretion without any notable
alteration in the walls of the duct or cyst, or in the secreting structure of
the gland itself, yet, in the second period, in the kyste conjirme, changes
occur which cannot be passed over unnoticed. Here the cyst walls be-
come thick, fibrous, tough, cartilaginous, or even ossified. Their in-
ternal surface may be smooth, or may present changes similar to those
which occur on the internal surface of arteries, namely, fatty or chalky
precipitations or aggregations, such as are seen in the later stages of endo-
arteritis. In other instances the walls of very large or old cysts become
the seat of albuminoid or of purulent infiltration. The mischief does not
however stop here ; the constantly enlarging cyst, with its thickened and
hardened walls, encroaches upon the substance of the gland itself, and the

1 Ancelet, Janeway. 2 Curnow. 3 Baillie.

4 Gould, op. cit. § 575.

5 Recklinghausen, op. cit. i. a. 6 Gould.

1 Recklinghausen, Ancelet, Becourt Duponchel, Soc. Med. d 'Emulation, Paris,

1824, tome ix. p. 76.

8 Recklinghausen, Gould.- 9 Krebs, Friedreich, etc.

No. CLXXII Oct. 1883. 27

418 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

result of this pressure is seen in morbid alterations of the gland paren-
chyma. Through chronic interstitial growth and induration the entire
gland structure, even to its last acinus, atrophies, loses its function, and
is completely destroyed, or again is entirely replaced by adipose tissue.

The nature of the contents of pancreatic cysts varies so constantly
that it would be impossible to embody in any one description all of the
peculiarities met with. In some cases cysts were found filled with the
altered secretion of the gland; in others, with a pure mucus; again,
with a serous fluid ; but, in a large proportion, products of retrograde
tissue metamorphosis, broken-down cells, cholesterin crystal, purulent
matter, or blood extravasations, with crystals of hsematoidin, were present.1

Lastly, as has been already mentioned, calculous concretions are some-
times formed within old pancreatic cysts. Under the head of Acne Pan-
creatica, the contents of small cysts have been described at sufficient length
in a former section.

The quantity of fluid present in a cyst will, of course, vary with its
size ; the largest amount of which we have record was between ten and
fourteen ounces.

Many and varied are the changes induced in the surrounding tissues
and organs by the presence of pancreatic cysts ; in fact, the contents of
both the epigastric and hypochondriac areas may become more or less in-
volved by the proximity of the diseased structures, and present the most
remarkable variety of pathological processes. Those which most properly
concern us are such as will, if accurately understood, be of use in enabling
us to recognize during life the seat and nature of the disease. These
lesions are, as a rule, simply the result of pressure, and will necessarily
vary with the size and situation of the tumour. And, again, as an aneu-
rism of the thoracic aorta, by pressing upon the trachea, without neces-
sarily causing any alteration in its structure, will produce marked if not
fatal symptoms ; so a cyst of the pancreas, by mechanical pressure alone,
will endanger if not end life. The changes which are ordinarily found
consist, in the majority of cases, in the formation of morbid adhesions,
from which the most singular distortions result. None of the contents of
these regions escape implication. The portal vein,2 inferior cava,3 and
splenic vein ;4 the pylorus,5 duodenum,6 colon,7 gall-bladder, and biliary
passages ;8 the stomach,9 liver,10 spleen,11 and right kidney ;12 and, lastly,
the solar plexus of nerves ;13 may all be structurally involved or locally
displaced, rendering diagnosis most difficult, and post-mortem examination
most unsatisfactory.

1 Pepper, Centralblatt fur die Med. Wissench. 1871, p. 156.

2 Dufresne, Recklinghausen. 3 Dufresne, Klebs.

4 Recklinghausen. 5 Fournier. 6 Gould, Dufresne, Fournier.

7 Fournier, Parsons. 8 Dufresne, Fournier. 9 Gould, Recklinghausen.

10 Gould. 11 Recklinghausen. 12 Fournier.
13 Recklinghausen.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 419

In the positions occupied by cystic enlargements of the pancreas, there
is not enough similarity to enable us to deduce any clinical 'laws. Thus
the tumour may be situated below the right lobe of the liver, and between
the intestines and the posterior wall of the abdomen,1 at the entrance of
the common duct into the duodenum,2 between the left end of the stomach
and the upper end of the spleen,3 midway in the pancreas,4 or in the left
hypochondrium.5 Finally, with regard to their termination, large pan-
creatic cysts may rupture, their contents being discharged into the duo-
denum, stomach, or peritoneal cavity, and so cause death.6

Before closing our remarks upon cysts of the pancreas, the subject of
hemorrhagic cysts is deserving of notice, and with it will be incorporated
a short account of hemorrhages into the pancreas, for, owing to the close
analogy which exists between these two conditions, it is thought desirable
to discuss them together.

Old pancreatic cysts frequently contain more or less blood (generally
disorganized, and of a chocolate-brown colour), which, if coagulated, con-
stitutes the so-called haematoma.7 On the other hand, fresh, red extra-
vasations are occasionally met with. It is necessary, in speaking of
hemorrhage proper, to distinguish between that form which results from a
passive congestion of the gland, dependent upon some central obstructive
disease, along with chronic inflammatory changes in the vascular system,8
and hemorrhages which take place into the gland, the result of the rupture
of vessels which have undergone a primary fatty degeneration.9 These
constitute the so-called apoplectiform hemorrhages into the pancreas.
The second of these conditions is admirably illustrated by three cases, the
report of which was published in a foreign journal a few years since.10 In
the first the individual was apparently in perfect health ; in the second,
an epileptic, otherwise healthy; in the third, a drunkard. They were all
quite corpulent. In each case death occurred suddenly, and without ap-
parent cause, while after death extensive fatty degeneration of the pan-
creas was observed. The hemorrhage in one case was more of the
nature of a bloody infiltration of the gland substance. In another the
infiltration was also observed around the gland ; while in the third there
was a somewhat extensive hemorrhage into the pancreas. In two of these
cases there was also an effusion of blood into the duodenum. Since the
quantity of extravasated blood was in no case sufficiently large to bring

1 Gould. 2 Dufresne. 3 Clark.

4 Recklinghausen. 5 Parsons. 6 Friedreich, Pepper, Klebs.

7 Klebs, Ancelet, ann. med. Stork, Vin. Wien, 1757, Gould, Duponchel, Clark, Pep-
per; Gros, Archives Gen. de Med., Paris, 1849, IVe serie, vol. xix. p. 215.

8 Friedreich, Stork ; Rugg, London Lancet, May 18, 1850 : Fatal Hemorrhage from
Pancreas.

9 Friedreich.

10 Zenker, Tagblatt der 47 Versammlmig deutsches Naturforscher und Aerzte in
Breslau, 1874, s. 211.

420 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

about speedy dissolution from hemorrhage, i. e., direct loss of blood ; and
since in each case great hyperemia of the semilunar ganglion was noticed,
•without structural alteration in nerve cells or fibrillse, the cause of instan-
taneous death is explained on the theory, that the suddenly enlarged
pancreas, by pressure on the semilunar ganglion, and solar plexus of
nerves, produced an immediate arrest of the heart, by a reflex inhibition
exerted through the vagus nerve, as in Goltz's familiar experiment with
the frog.

6. Inflammatory Changes. — Of those secondary conditions which are
the result of the presence of calculi within the pancreas, duct dilatation
and cyst formation are certainly the most interesting when viewed from a
pathological standpoint ; and, moreover, when excessive, by revealing to
the diagnostician the presence of a local swelling, serve to explain many
obscure and intractable symptoms. But, while acknowledging the greater
interest of that part of our subject, it is necessary to enumerate at least
the alterations of structure which result when the pancreas becomes the
seat of stony concretions. These are in the main similar, when con-
sidered as mere pathological processes, to changes occurring in any other
gland, and depend primarily upon inflammation. The pancreas may thus
become the subject of acute, subacute, or chronic inflammatory processes ;
those which to us are of the greatest interest being the acute, suppurative,
and the chronic interstitial inflammations. There is no doubt that the
duct-wall first becomes the seat of change, and a condition is described
in which it was found thickened, through an increase in the surrounding
connective -tissue substance, its lining cells having undergone marked
alterations.1 No accurate description of duct inflammation resulting from
the irritation produced by a calculus is, however, given by systematic
writers. Dr. Eoland G. Curtin, of Philadelphia, has reported a case of what
he believes to have been a primary catarrhal inflammation of the ducts of
the pancreas.2 The microscopic examination of the specimen showed a
condition of things not very dissimilar to the description just given. Dr.
Curtin suggests, however, that the inflammatory process may have begun
in the duodenum, and from thence involved the pancreatic duct second-
arily, this theory being borne out by the fact that during life symptoms of
intestinal derangement preceded any evidences of pancreatic obstruction.
Whether a primary catarrhal inflammation of the pancreatic ducts is pos-
sible, must of course remain an open question ; but that such an inflam-
mation, whether primary or secondary, will give rise to subsequent changes
in the pancreas, should it affect the duodenal end of the duct of Wirsung

1 Cornil and Ranvier, loc. cit.

2 A Contribution to the Pathology and Therapeutics of the Pancreas. A paper read
before the Pennsylvania State Medical Society, 1881, by Dr. Roland G. Curtin, of
Philadelphia.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 421

alone, or be confined to the smaller branch ducts, is a fact proven by the
case of Dr. Curtin, and by the results recorded by other investigators.

It is possible, though of rare occurrence, to have an inflammation accom-
panied by deposits of purulent matter in the gland structure. We have been
able to collect but three cases in which this condition was the result of the
presence of calculi. In one, the head of the pancreas was merely touched
with points of ulceration ;l in a second, an abscess of the size of a nut,
containing much purulent matter and many calculi, was found in the
centre of the gland ;2 while in a third, a very large abscess, containing
calculi, and having for its walls the dilated head of the gland, was dis-
covered.3 Such abscesses may open in any direction ; the second referred
to discharged a part of its contents into the stomach through a hole the
size of a thumb.

A chronic interstitial inflammation of the pancreas is described, which
by hyperplasia of connective tissue may lead to hypertrophy, atrophy,
induration, and fatty degeneration. The condition of hypertrophic cir-
rhosis is rare. Atrophic cirrhosis is common, and the induration accom-
panying it is marked. This induration, which may give to the gland a
feeling of cartilaginous hardness, lias very often been confounded with
scirrhus, so that in many cases of supposed cancerous disease, there is no
doubt that the real lesion was one of cartilaginous induration.4

a. Fatty Changes. — In speaking of fatty disease of the pancreas, a dis-
tinction must be drawn between the condition known as lipomatosis and
the true fatty degeneration, or transformation graisseuse. In the first
of these, fat develops in the interacinous connective tissue, or else on the
periphery of the gland, pushes its way in, and produces atrophy and even
complete destruction of its proper secreting structure, the whole gland
being converted into a mass of fat.5 The second is a true fatty metamor-
phosis, beginning in the gland cells, and leading to complete destruction
of the acini and subsequent atrophy of the whole viscus.6 These two
conditions are to a certain extent inseparable, and since no microscopic
examination was made, it is impossible to say whether, in the two reported
cases of pancreatic calculi in which fatty changes in the gland were the
result, fatty infiltration or fatty degeneration existed alone or together.7

1 Dufresne. 2 Muhlbauer. 3 Fournier.

4 Cawley, Salraade, Schupman, Friedreich, and Klebs.

3 Maier, Archiv der Heilkunde, Leipsig, 1865; Fall von ausgezeichnete (r) Ver-

fetlung der Pankreas, s. 168 Klebs, op. cit. s. 562 Friedreich, op. cit. p. 624.

Cornil et Ranvier, op. cit. tome ii. p. 970 : Degenerescence graisseuse Becourt,

op. cit. p. 50.

6 Jones, Med.-Chirurg. Trans., London, 1855 : Observations respecting Degeneration

of the Pancreas, p. 195 Salter, Encyclopedia of Anatomy and Physiology, Part

XLIV ..Rokitansky, Lehrbuch der Patholog. Anat., 1861, iii. s. 313, 369 Be-
court, op. cit. p. 50 Ancelet, op. cit. p. 29 Bock, Lehrbuch der Pathol. Anat.,

Leipsig, 1817 : Pankreas, § 7, s. 669. ......Cruveilkier, loc. cit.

7 Clark, loc. cit., Recklinghausen, op. cit. 16.

422 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

II. Symptomatology.

In endeavouring to inform ourselves with regard to the symptomatology
of calculous disease of the pancreas, the same difficulties are encountered
as beset our studies of its pathological anatomy. The older writers are as
obscure in their description, and brief in their enumeration of symptoms,
as they are obscure and brief when pathological conditions were to be
described or enumerated. And more, in modern times, instances of cal-
culous disease of this gland are rather regarded as curiosities to be alluded
to by a pathological anatomist, than as subjects worthy the study of a
clinician. And considering, as we must, the great number and variety of
those diseases with which the active practitioner daily comes in contact, and
which still remain so intractable to all therapeutic resource, we can well
understand how a condition, relatively so rare as calculous disease of the
pancreas, a condition about which we can learn so little from literature,
either past or contemporary, whose history and causation are so obscure,
whose diagnosis is so difficult, and whose treatment is so ineffectual,
should fail to receive more than superficial study, or passing mention.
Therefore, when, as here, we leave aside the study of the lesion, its cau-
sation, and its treatment, and confine ourselves solely to those signs and
symptoms which would lead us to infer its presence, we cannot hope to
find anything so characteristic as is revealed by the physical exploration
of the chest, or the temperature curve of a fever.

The pancreas, it is true, plays a most important part in the great act of
digestion, but when, by disease, its functions are perverted or destroyed,
so intimate are both its structure and functional connection with the other
members of the same great system, and so great may be its pathological
alterations, without there being any tangible evidence of the same, that
from the start our diagnosis becomes most difficult. But even should dis-
ease be located in the pancreas, it would be almost, if not completely
impossible, to differentiate, for example, between cancerous and calculous
disease of that organ. It will be our endeavour, in the following pages,
to make, from a study of the cases at our command, a complete, but we
fear an unsatisfactory recapitulation of the various views advanced from
time to time upon the symptomatology of this disease, and to give due
weight to such as seem to us of the greatest clinical importance, both in
pure, uncomplicated cases of pancreatic calculi, and in those accompanied
by disease of other organs and tissues.

It is most important, while endeavouring to explain the symptoms of
calculous disease of the pancreatic ducts from a pathological standpoint,
to remember two things, already briefly referred to, namely, the anatomi-
cal position and local relations of the pancreas, and its physiological func-
tion as a most important digestive organ. Deep-seated and surrounded
as it is by structures whose organic and functional integrity is of such
importance to the well-being of the economy, it is easy to see how, for

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 423

example, from mere enlargement, by mechanical pressure, it could cause
changes and disturbances the most grave. In one case, a pancreas, three
times its normal size, and filled with concretions, so pressed upon the
aorta as to produce an enormous aneurismal dilatation of that vessel
above the point of obstruction.1 In another, the return flow of blood
through the inferior cava was interfered with to such an extent as to cause
ascites with oedema of both legs.2

In a third, where the spleen was found much softened and disinte-
grated, in default of a more suitable explanation, the lesion is attributed to
compression of the splenic artery and veins by the enlarged, earthy, and
indurated pancreas ;3 while, from pressure upon the excretory ducts of
the liver, we find jaundice from retention, a condition by no means un-
common.4 When we consider, finally, the local relation between the pan-
creas and the cosliac plexus of nerves, we find ourselves entering upon a
branch of our subject the most interesting.

In a large number of the reported cases of pancreatic calculi, pain is
mentioned as one of the most constant, and, at the same time, one of the
most annoying of symptoms. But it is not one kind of pain only that we
find described, but rather two, differing essentially in character one from the
other, and having, in most cases, two entirely distinct modes of causation.
The one dull, heavy, a sense of weight, a sense of uneasiness, located in the
epigastrium, lasting, in some cases, throughout the entire attack,5 while, in
others, it preceded the actual illness of the patient by many years.6 The other,
sharp, severe, sudden in its onset, irregular in its accession, spontaneously
relieved, yet reoccurring when least expected.7 Separately or together these
two kinds of pain, in different degrees of severity, occur very often in cases of
calculous disease, and, in seeking for their mode of causation, two conditions
are, we think, necessary to afford a satisfactory explanation. The various
sensations at first referred to, varying in degree from a feeling of uneasiness
or of weight, to pain, generally constant, and, in some instances, quite severe,
are due, it would appear, to the pressure of a hard and enlarged pancreas
upon the coeliac plexus of nerves. Although it would seem, at first sight,
as if the mere presence of calculi within the pancreas would be quite suffi-

1 Salmade, loc. cit Portal, loc. cit Dufresne, loc. cit.

2 DufrSsne, quoting Portal's second case, see Maladie du foie, obs. f, p. 300

Clark, loc. cit Muhlbauer, loc. cit., noticed oedema of extremities of left side only.

3 Wilson, loc. cit.

4 Meckel, loc. cit Fournier, loc. cit Dufresne, ibid Gould, op. cit. § 576.

Henry, loc. cit Friedreich, op. cit. p. 618 Galiati, loc. cit.

5 Mercklin, loc. cit Wilson, loc. cit Clayton, loc. cit Muhlbauer, loc.

cit Fournier, loc. cit Henry, loc. cit Gould, op. cit. § 576 Elliotson,

Med.-Chfrurg. Trans., loc. cit.

6 Mercklin, ibid Gould, ibid Henry, ibid Galiati, ibid Pepper, Medi-
cal Ward Notes, Hospital of the Univ. of Pa., 1880.

7 Schupmann, loc. eit Wilson, loc. cit Gould, loc. cit Clayton, loe. cit.

......Dufresne, loc. cit.< Clark, loc. cit .Fournier, loc. cit .Pepper, loc. cit.

424 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

cient to account for these subjective symptoms, yet, as it has been remarked,
the relative insensibility of the excretory ducts of this gland, as compared
with those of the liver or kidney, renders it improbable that much incon-
venience or pain would be caused, even though they were distended by
calculous concretions.1 Whereas, if the coeliac plexus could be so com-
pressed (under circumstances such as we have above described) as to
suffer atrophy, and even complete destruction of its ganglionic cells,2 it
seems very probable that this, or even a far less degree of pressure, would
produce pain. Our explanation is further borne out by the fact, that, when
the recumbent posture is assumed, the pain grows worse,3 while occasion-
ally it radiates to the back, chest, and even right shoulder.4 We are,
therefore, led to conclude that this symptom, pain, is the result of pres-
sure, and may, as has been suggested, be called a cceliac neuralgia.3

But when we come to consider the other kind of pain described, another
and more suitable explanation offers itself. This, the true pancreatic
colic, the result of the rapid distension of the duct of the gland by a stone
forcing its way into the duodenum, the walls of the duct spasmodically
contracting upon it, has been referred to in a former section. From a
diagnostic point of view this symptom has but little weight, for it is diffi-
cult to tell, from the character or location of the pain, whether a biliary or
a pancreatic calculus is being passed ; as a pancreatic calculus, in its pas-
sage through the last part of the duct of Wirsung, by pressure on the common
duct, would produce jaundice as effectually as would one of biliary origin.6

Before leaving this part of our subject, it is wTell to refer briefly to
the existence of mellituria, as a symptom of calculous disease of the
pancreas, since it occurs with sufficient frequency to demand attention.'
In so much obscurity is the morbid anatomy of diabetes mellitus in-
volved, that it would be alike useless and impossible, within the limits of
this paper, to go at length into the theories that have been advanced as
to its causation. Suffice it to say that, whereas, in each and every organ
of the body, the morbid change, of which the con dition known as melli-
turia is the result, has been from time to time located, it seems highly
improper that the pancreas, as one of the organs of importance, should
not bear its part of the burden. In one of two8 cases of calculous disease
(where, during life, mellituria was present), in which a careful examina-
tion of the coeliac plexus of nerves was made after death, changes consist-

1 Gross, loc. cit Bigsby, loc. cit. 2 Klebs, op. cit. s. 544.

3 Wilson, loc. cit Gould, op. cit. § 576.

4 Elliotson, Med. Ch. Trans., loc. cit Fournier, loc. cit Pepper, Med. Ward

Notes, Univ. Hosp., loc. cit.

5 Klebs, op. cit. s. 544. 6 Friedreich, op. cit. p. 61S.

7 Recklinghausen, op. cit. I. a. and b Elliotson, Med. Chirurg. Trans., loc. cit

Cawley, loc. cit Klebs, op. cit. s. 544 Chopart, Maladies des voies urinaires.

Cf. Klebs, loc. cit Pepper, Med. Ward Notes, Univ. Hosp., loc. cit.

8 Klebs, op. cit. s. 544 Recklinghausen, loc. cit.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 425

ing in the destruction of a certain number of its ganglionic cells could be
observed. Now, since it is affirmed that extirpation or atrophy of the
coeliac plexus will give rise to the presence of sugar in the urine,1 it is
plain how secondary changes in this plexus of nerves of sufficient gravity
to bring about this condition, could be produced by the pressure of a
pancreas, made large and hard by the presence of calculi. And, to go
further, atrophy of the pancreas will follow these changes in the coeliac
plexus as atrophy of the submaxillary gland will follow section of the
vaso-motor nerves supplying it. The appearance of fatty stools after
mellituria would seem to prove this.2 There is no doubt at least that
atrophy of the coeliac plexus will produce a vaso-motor paralysis through-
out the whole area occupied by the pancreas, for all the vessels have been
seen enormously dilated, and the spleen engorged and swollen.3

In regard to those symptoms which are the result of an improper per-
formance of the physiological functions of the gland, due to the presence
of calculi within it, we can only enumerate, without endeavouring to ex-
plain, the phenomena mentioned in the reported cases. When the main
excretory duct of the pancreas was entirely blocked up by concretions,
the symptoms of digestive derangement were of course more marked than
when the outflow of the pancreatic juice was in whole, or in part,
permitted. In thirteen cases, we find the actual illness of the patient
preceded for a variable length of time, and ushered in by more or less
marked symptoms of gastro-intestinal derangement, accompanied in some
cases by abdominal pain. During the progress of the disease, these symp-
toms become more persistent, and increased in severity, so that, in many
cases, the termination of the organic disease in complete duct obstruction
placed a limit to the patient's life, while, as has been remarked, we find
changes in other parts of the body capable of spoiling life, but not of
causing death.

In four cases, where, upon post-mortem examination, calculi were found
in the pancreas, vomiting was one of the most distressing symptoms pre-
sent during life.4 In three others, bloody vomiting was noticed.5 In six
cases, diarrhoea was present ;6 in four, mel^na ;7 while constipation was
observed in six,8 and fatty stools in three.9

The presence of fat in the stools is a symptom of great importance in
the recognition of pancreatic disease,10 but that it is not of absolute diag-

1 Klebs, op. cit. s. 544.

2 Fles, cf. Klebs, op. cit. s. 544. 3 Klebs, loc. cit.

4 Cases reported by De Graaf, Mercklin, Galiati, and Schupraann.

5 Wilson, Gould, Clayton.

6 DeGraaf, Gould, Dufresne, Henry, McCready, Janeway.

7 DeGraaf, Elliotson, Gould (two cases).

8 Galiati, Cawley, Schupmann, WilsoD, Clark, Wtn. Pepper.

9 Elliotson, Gould, Clark.

10 This subject will be found discussed at length in the Medico-Chirurgical Trans.,
London, 1832, vol. xviii. p. 76, and elsewhere in the same volume by Lloyd & Bright.

426 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

nostic value is proven by the well-known fact, that the same condition
will follow upon the obstruction of the biliary passages. For, while the
main action of the pancreatic juice upon fats is to cause their emulsifica-
tion, this power is possessed, though to a less extent, by the bile, which,
like the succus entericus, emulsifies fat, but does so to a degree entirely
insufficient to meet the needs of the economy. Therefore, it must be
remembered that not the bile alone, nor the pancreatic juice alone, can
properly digest fats, but rather that they must act together, mutually
aiding one another in the performance of this joint function. But since,
as an emulsifying agent, the pancreatic juice is far more active than the
bile, it might be argued that fatty stools would be more symptomatic of
pancreatic than of hepatic disease. But, even should jaundice and fatty
stools both be present in the same case, it by no means follows that they
together point to biliary obstruction, for, as has been shown, a pancreatic
calculus, lodged in the duct of Wirsung just as it enters the duodenum,
may, by pressure on the common duct, prevent the escape of bile, and
give rise to jaundice, while, at the same time, by this obstruction, but
more by preventing the outflow of the pancreatic juice, cause the appear-
ance of fat in the excreta. In proof of the first of these assertions, it
may be said that in two instances of calculous disease in which the ex-
creta presented a pale or clay-coloured appearance, upon post-mortem
examination, no morbid alteration of sufficient gravity to cause this con-
dition was found in the liver, and the dilated ducts contained no obstruc-
tion, the common duct opening freely into the duodenum, while the pan-
creatic duct was impervious, being blocked up with calculi.1

It is strange that the presence of fat is noted in so few cases of this
pancreatic disease, and, since the condition is one of some rarity, we will
append an abstract of the three cases in which it was observed.

Case I.2 H. M., oet. 57 ; derangement of digestion for some years; fat
noticed in urine, one month later also in excreta. In a short time fat
oozed away from lower bowel without intermission or volition. Pain, pro-
gressive emaciation, and death from exhaustion. Autopsy: Liver con-
gested, ducts dilated but healthy. Pancreatic duct at duodenal end com-
pletely blocked up by a mass of calculous matter.

Case II.3 W. P., set. 45, had pain, diarrhoea, melaena ; blood disap-
peared from, and fat appeared in stools and urine ; amount of fat and
severity of pain diminished as death approached ; sugar appeared in urine ;
exhaustion, death. Autopsy : Liver, gall-bladder, and bile-ducts sound.
Pancreatic duct and its larger branches crammed with calculi.

Case III.4 Man, set. 40, had several attacks of hemorrhage from bowels ;
diarrhoea and constipation alternated ; tenderness in epigastrium, pain ;
fat in stools (apparently only after articles containing fat had been eaten) ;
no fat in urine ; jaundice ; death in coma. Autopsy : Liver rather small
and dark-coloured ; ducts dilated, contained no obstruction, free opening
into common duet. Pancreatic duct obliterated at duodenal end.

1 Gould, op. cit. § 576 Clark, loc. cit.

2 Clark. 3 Elliotson, Mcd.-Chir. Trans., loc. cit. 4 Gould, § 576.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 427

There have been discussed up to this point the symptoms which may be
considered most characteristic of calculous disease of the pancreas, but
there are certain others mentioned which it may be well to refer to. The
appetite, " inordinate,"1 " craving,"2 " ravenous,"3 especially in those
cases where large quantities of fat passed away undigested, has been said
to be impaired, tending in some cases toward complete anorexia.4 As a
natural result of the crippled condition of the nutritive processes, pro-
gressive emaciation,5 accompanied by debility,6 and followed by extreme
prostration and exhaustion, would be expected.7 Nothing worthy of com-
ment is to be noticed with regard to the circulatory, respiratory, or nervous
systems ; whatever derangement we find mentioned can all be explained
by the presence of other lesions, complicating the pancreatic disease. A
most interesting condition is met with when wre come to consider changes
present in the urine. It will be seen, in the three cases already recorded,
in which fat was found in the stools, that in two, fat passed away with
the urinary secretion, and indeed, in one, made- its appearance one month
before it was detected in the excreta, and in such quantity as to float,
when cool, in greasy cakes upon the surface.8 Lastly, a peculiar colour of
the skin, which is believed by some to be pathognomonic of pancreatic
disease, must be mentioned, in connection with three cases of calculous
affection in which it was observed. In them the appearance presented is
variously described as being unhealthy, pale-yellow, dirty or earthy, and
seems, except in one case, in which it was confined to the face, to have
been general.

The ordinary methods of physical examination offer some partial assist-
ance in the recognition of calculous disease of the pancreas. By palpa-
tion it is most difficult to recognize the position of this organ in health.
" By deeply depressing the abdominal walls about a hand's-breadth below
the umbilicus, by then rolling the subjacent parts under the hand (the
stomach and colon must be empty), it might be possible to detect it in an
individual who is thin and whose tissues are lax."9 In a case where the
size of the pancreas is only slightly increased by the presence of calculi,
on careful palpation, it might be possible to detect a feeling of resistance,
although when the gland is markedly enlarged, as in one of the reported
cases of this affection (by an enormous stone formation situated in its
tail, and the presence of a scirrhus at its head), a tumour of cartilaginous
hardness might be perceived after careful examination of the abdomen.
In the case referred to, the tumour was flat, slightly movable, and sensitive
to the touch.10 This is the only instance of this affection in which a

1 Chirk. 2 Gould. 3 Wm, pepper.

4 Schupmann Foumier. 5 Clayton, Clark, Wm. Pepper.

6 De Graaf, Dufiesne, Clark. 7 Fournier.

8 Clark, Wilson, Henry, Janeway.

9 Sir Wm. Jenner, British Med. Journal, Jan. 16, 1869, p. 42. 10 Schupmann.

(

428 Johnston, Calculous Affections of the Pancreatic Ducts. [Oct.

local examination was made, except in three instances where a large
cyst was the result of duct obstruction,1 and in a fourth, where an enor-
mous abscess, situated in the head of the gland and filled with calculi,
caused the appearance of a localized epigastric swelling.2 The diagnosis
of abdominal tumours, as is well known, is extremely difficult, and is not
a subject which it is our intention to discuss. To distinguish such a con-
dition as we first described from a scirrhus involving the pyloric end of
the stomach, or an induration of the left lobe of the liver, would, by
physical exploration alone, be most difficult ; while the characteristic
thrill and bruit of an aneurism might be simulated by the rush of blood
through an abdominal aorta compressed by an enlarged pancreas.3 And
so it is with cysts of this viscus, which can only be recognized by their
situation, deep in the region of the pancreas, their round or oval shape,
smooth surface, and the sense of fluctuation imparted to the touch,4 while
in both these conditions the general symptoms, which have been mentioned
as more or less characteristic of calculous disease, would be of aid in de-
termining upon a diagnosis.

III. Duration and Termination.

No decided laws can be laid down with regard to the duration and ter-
mination of this affection. So rare is it to find a pure uncomplicated case
of calculous disease, that any generalization would be impossible ; never-
theless, taking all those cases in which both clinical history and post-
mortem examination are recorded, we find death from exhaustion or
asthenia one of the most frequent of all terminations. In four cases,
diabetes was the cause of death ;5 in one, rupture of an aneurism produced
by the disease itself;6 in another, internal hemorrhage, consequent upon
a laceration of the pancreas, the calculus escaping into the peritoneal
cavity.7 Pneumonia is referred to in one case as hastening the fatal issue,8
while aortic disease,9 an accident of pregnancy,10 and albuminuria and
phlebitis11 are each mentioned as having placed a limit to life.

Bibliography. — De Graaf, Tractat. anat. med. de succi pancreat., Lugd. Batav.,
1671, cap. vii. p. 112. Mereklin, Ephem. nat. cur. decur., Frankfort and Leipsig,
1678, Ann. 8, obs. 50, p. 78. Eller, Collection Acadernique, Paris, 1755, tome x. p. 85.
Ileckel, Koreff, Dissert, inaug. med. sistens theoret. cousid. Icteri, Halse magd., 1759,
§ 12, p. 16. St'drck, Ann. med. Vindobon, 1760, t. ii. p. 245. Matani, Naturen genees-
kundige Bibliotheek, gravenbage, 1765 : and Gottingische anzeigen von Gelehrten
sachen, 1765, No. 10. Lieutaud, Hist. anat. med., Paris, 1767, liber 1, sect. viii. obs.
1045, p. 244. Foumier, Journ. de med. chirurg. pharm., Paris, 1776, tome xlv. p. 149.

1 Gould, § 576 Dufresne, quoting Portal's 2d case. 2 Fournier.

3 The diagnosis in such a case might be assisted, as suggested by Prof. Wm. Pepper,
by placing the individual in the genu-pectoral position, and then using the method of
palpation.

4 Friedreich, Cysts, op. cit. p. 615.

5 Cawley, Elliotson, Recklinghausen. 6 Salmade. 7 Clayton.

8 Janeway. 9 Curnow. 10 Schmitt. 11 McCready.

1883.] Johnston, Calculous Affections of the Pancreatic Ducts. 429

Sandifort, Obs. anat. patholog., Lugd. Batav., 1777, lib. iii. cap. iv. p. 73. Cawley, Lon-
don Medical Journal, London, 1788, vol. ix. part iv. p. 286. Salmade, Recueil period-
iqne de la 60c. de med. de Paris, 1797-1798, tome iii. p. 454. Portal, Cours d'anat.
med., Paris, 1803, tome v. p. 356. Schmitt, Zweifelhafte Schwanger, Wien, 1818.
JInJdbauer, Neue Notizen (von Froriep) , Weimer, 1822-1847. Duponchel, Soc. med.
d'Bmulat., 1824, t. ix. p. 76. Gendrin, Histoire anat. des inflam., Paris, 1826, tome ii.
p. 263. Lecannan, Journ. de pharm. et de cbim., Decembre, 1827, p. 626. Pemberton,
On Various Diseases of the Abdominal Viscera, Richmond, Va., 1830, chap. iv. p. 64.
Becourt, Recherches sur le Pancreas, These, Strasbourg, 1830, § 5, p. 69. Baillie, The
Morbid Anatomy of the Human Body, London, 1812, p. 115, and 1833, p. 222. Bigsby,
Edinburgh Medical Journal, 1835, vol. xliv. p. 97. Mondiere, Archiv. gen. de med.,
II eerie, Paris, 1836, t. xii. p. 147. Schupmann, Hufeland's Journal, 1841, xcii. Bd.
§ iii. s. 41. Engel, Oesterreich med. Jahrbucher, 1841, xxiii. u. xxiv. Bd. Wilson,
Med. Chirurg. Trans., London, 1842, vol. xxv. p. 42. Bevilliers, Revue medicale, no.
de Decembre, Paris, 1844, t. iii. p. 576. Gross, Pathological Anatomy, Phila., 1845,
p. 689. Goxdd, Catalogue of the Anatomical Museum of Boston Society for Medical
Improvement, Boston, 1847, §§ 575, 576, p. 173. Sc h vlze, Journal iiir der Chemie,
xxxix. p. 29. Rokitansky, Manual of Pathological Anatomy, Syd. Soc. London, 1849,
vol. ii. § 2, p. 180 ; and Lehrbuch der Pathol. Anat., 1801, iii. s. 313, 369. Clayton,
The Medical Times, London, 1849, vol. xx. p. 37. Clark, London Lancet, Aug. 15,
1851. Bufresne, Traite de l'affection calculeuse du foie et du pancreas, Paris, 1851,
Article deuxieme, p. 494. Virchow, Verhand. der med. physik. Gesellschaft zu Wurz-
burg, 1852, II. Bd. s. 53 u. III. Bd. s. 368. Virchow, Die krankhaften Geschwiilste,
Berlin, 1863, I. Bd. s. 276. Jones & Sieveking, A Manual of Pathological Anatomy,
Phila., 1854, p. 532. Henry, Journ. de chim. med., IV. £erie, Paris, 1855, t. i. p. 273,
et La France med. et pharm., 3 annee, Paris, 1856, No. vi. p. 42. Jones, Med.-Chirurg.
Trans., London, 1855, p. 195. Cruveilhier, Traite d'anat. pathol. gen., Paris, 1856, t.
iii. p. 365. Ancelet, Essai analytique sur l'anatomie pathologique du pancreas, These,
Paris, 1856, t. i. p. 26. McCready, New York Medical Journal, 1856, p. 78. Hoppe, Vir-
chow's Archiv, 1857, xi. Bd. s. 96. Parsons, British Medical Journal, June 6, 1857, p.
475. Becklinghavsen, Virchovv's Archiv, Berlin, 1864, 30 Bd. s. 360. Ancelet, Etudes
sur les maladies du pancreas, Paris, 1864. llaier, Archiv der Heilkunde, Leipsig, 1865,
s. 168. Jenner, British Medical Journal, Jan. 16, 1869, p. 42. Comil et Banvier,
D'Histologie pathologique, Paris, 1869-1873, tome ii. p. 974. Pepper, Centralblatt fur
die med. Wissensch., 1871, p. 156. Belafield, Handbook of Post-mortem Examinations
and of Morbid Anatomy, New York, 1872, p. 203. Janeway, New York Medical Record,
1872, vol. vii. p. 357. Curnow, Trans. Pathol. Soc, London, 1873, vol. xxiv. p. 136.
Zenker, Tagblatt der 47. Versam. deutsch, Natur. u. Aerzte in Breslau, 1874, s. 211.
Schmidt, Annal de. Chem. u. Pharm., 1854, xcii. p. 33. Wilkes & Moxon, Lectures on
Pathological Anatomy, Phila., 1875, p. 470. Flint, Text-book of Human Physiology
New York, 1876, p. 272. Klebs, Handbuch der Patholog. Anat., Berlin, 1876, I. Bd. s.'
544 u. 547. Carpenter, Physiology, Phila., 1876. Friedreich, Ziemssen's Cyclopedia of
Medicine, New York, 1878, vol. viii. pp. 615-618. Comil and Banvier, Manual of Pa-
thological Histology, Translation, Phila., 1880, p. 581. Foster, Text-book of Physiology,
American edition, Phila., 1880, p. 333. Wm. Pepper, Medical Ward Notes, 1880
Hospital of the University of Penns}dvania.

Omissions. Galiati, De morbus duobus observ., 1758, p. 26, or Comment. Bonon.,
t. iv. p. 34. Sugg, London Lancet, May 18, 1850. Boch, Lehrbuch der Pathol. Anat.,
Leipsig, 1847, § 7, s. 669.

430

Harris, Classification of the Porro Operations. [Oct.

Article VI.

Classification of the "Porro (?) Operations." What is a True
porro-c^esarean operation, and what other forms of uterine
Ablation in Pregnant Women have been erroneously called
"Porro," and should be separately classified. By Robert P-
Harris, A.M., M.D., of Philadelphia.

Seven years have passed since Prof. Porro, then of Pavia, and now of
Milan, instituted the modification of the old Cesarean operation which
bears his name, designing thereby, if possible, to diminish the great mor-
tality of the mothers whose deformed or obstructed pelves required that
they should be delivered, by abdominal incision, and especially in the large
maternity hospitals of Europe, in which but very few of the subjects
escaped death. In fact, so great was the maternal mortality that, in some
of the large cities, as Paris and Vienna, a fatal result was universal. The
classic method, as it has been called under a misconception of its age, was
intended to save two lives wherever possible, and to avoid the destruction
of the foetus. By this old operation, whose age cannot be established be-
yond four centuries back from any reliable evidence, the child was readily
saved, where it was performed in due season, but, as this was rarely done,
a large proportion perished, from having been too long subjected to uterine
pressure.

The title given by Prof. Porro to his method, viz., " Utero-ovarian
amputation as completive of the Ccesarean operation" conveys an idea of
its true character. The old operation is to be first performed, the foetus
removed, and the uterus made to contract ; then the plan is radically
changed ; the uterus is drawn through the abdominal wound ; its neck
is ligated by a wire constrictor tightened by screw-power ; the organ
is cut away above the loop, .and the stump is secured in the lower
angle of the abdominal wound. The design of this change is to avoid the
possibility of the escape of post-partum uterine fluids into the abdominal
cavity, and the dangers consequent thereupon, by converting the uterine
wound, with its disposition to gape open, into an open stump, external to
the body, and discharging externally under antiseptic dressings. This
method also possesses the additional advantage, that it may be performed
prior to labour, thus avoiding the exhaustion consequent upon this painful
effort of nature. Many operations have been performed before the ma-
turity of gestation, and many after labour had progressed for a short or
long period. And it is very evident that, as in the old operation, the
result will depend very much upon the condition of the woman at the time
of its performance ; if such as to make the prognosis favourable, a large
proportion will recover.

Although Prof. Porro is entitled to the credit of having performed the
first successful puerperal utero-ovarian amputation, and I think also of

1883.] Harris, Classification of the Porro Operations.

431

having the method bear his name, we are to remember that an unsuccessful
operation of a very similar nature was performed in this country in 1869,
by Prof. Storer, then of Boston, now of Newport, R. I. As the latter
failed in saving the life of the mother, there was no repetition of his
method in the seven years which elapsed between his case and that of
Prof. Porro. Had he succeeded, under the circumstances of extremity,
which compelled him to clamp and remove the uterus, it is not likely that
he would have had imitators in the sense that Porro has had, after an
elective operation, based upon a theory, obtained from the success of ex-
periments tried upon the lower animals, and again tried on the human female
with a similar result, the case being one of ordinary rachitic obstruction
of the pelvis.

1. Muller's Modification In the first eight Porro-Caesarean operations,

covering a period of twenty months, the original plan was adhered to,
with a loss of six women, all of the children having been saved but one.
A woman then came under the care of Prof. Miiller,.of Bern, whose con-
dition was such as to induce him to modify the method of Porro, hoping
thereby to escape the dangers of hemorrhage, and the risks from having
blood and noxious fluids pass into the abdominal cavity during the opera-
tion. This patient was the subject of malacosteon ; had been 3J clays in
labour; was in a febrile condition, and presented indications of septic
endo-metritis, with gas in the uterine cavity as an evidence of decomposi-
tion of the foetus. To secure her against the dangers mentioned, Prof.
Aluller made a long incision in the abdomen, drew out the uterus, carefully
protected the abdominal cavity against the entrance of fluid, put on the
wire constrictor and secured it, opened the uterus and removed its putrid
contents, and, finally, secured the stump as in the original Porro operation.
The patient recovered. The success of Miiller, and a belief in the value
of his method, caused many to imitate him, and although unsuccessful for a
time, such has been the general result that it has now a number of advo-
cates. It has not met with much favour in Italy, but has been repeatedly
preferred in Austria and Germany. The chief objections to the method,
are the long incision and the danger of losing the foetus from asphyxia.
This risk of loss is more apparent than real, if the uterus is rapidly evacu-
ated after its constriction ; but in a recent case under Prof. Carl Braun,
of Vienna, the foetus could not be resuscitated, owing to a little delay at
this point of the operation. Having seen two narrow escapes under the
method, I believe this to be one of the dangers to be especially guarded
against.

2. The " Esmarch bloodh ss operation" has been used in combination
with the twTo preceding methods. It was first tested by Prof. Litzmann, of
Kiel, a colleague of Esmarch, on June 14, 1878, and proved fatal from
septic peritonitis on the sixth day, not from any defect in the process, but
from an unfortunate occlusion of the os uteri, which prevented the escape

432 Harris, Classification of the Porro Operations. [Oct.

of fetid pus that collected after the operation in the cervical canal. This
combination of the Porro, Miiller, and Esmarch methods has recently
been revived with success in three consecutive cases by Prof. Carl Braun,
of Vienna. After the uterus is turned out, the elastic tube is made to
surround the cervix tightly, before the incision is made, so that there shall
be no loss of blood beyond what already exists in the vessels of the organ.
This has been found of special advantage in cases where the placenta is
located under the line of incision. In addition to the elastic tubing, the
constricting wire is to be passed around the cervix and held in readiness for
tightening, when the former is to be removed. If the Esmarch tubing is
not hurriedly applied, and the foetus quickly liberated, it will be lost.

3. Ligating and Dropping in the Stump. — Under the impression that
the cut cervix should and could be treated as a pedicle, several operators
have boldly tied it and dropped it in. It was first tried by Prof. Gustav
Veit, of Bonn (March 21, 1880), but with a fatal result. Wasseige ampu-
tated the cervix by double flap and stitched the two halves together after the
process of Schroeder, but lost his patient. Prof. Gustav Braun pocketed
and stitched up the stump in two instances, but both patients died. Prof.
Isaac E. Taylor, of New York, saved his case so far as the danger from
the dropped cervix was concerned, but lost her in twenty-six days, from
her own perversity in sitting up when he had warned her against the
danger.1 The fact that Prof. Veit, in a second operation (Sept. 18,
1880), and Dr. Kabierski, of Breslau (Jan. 15, 1883), did succeed in
saving each a patient in whom they dropped in the stump, only shows
that the method is not necessarily fatal ; but this need not encourage
others to imitate them. It is much to be regretted that this method is
so dangerous, as otherwise it would have several advantages over the
original Porro plan, which often makes an ugly drawn cicatrix, and
interferes more or less with the dilatation of the bladder.

4. Non- Ccesarean Utero-abdominal Amputations. — When a uterus con-
taining a foetus of four, five, or six months is removed, with perhaps a
large fibro-myoma, or mass of fibroid tumours, without the viscus being
opened at any stage of the operation, what propriety is there in denomi-
nating the ablation a Porro operation? Prof. Wasseige, on March 18,
1880, operated upon a woman nearly five months pregnant, who was affected
with a large cystic fibro-myoma. He did not open the uterus, neither did
he secure the stump as recommended by Porro. It was not a Cesarean
section at all, and yet it, and several others quite similar to it, have been
placed in the list of Porro-Csesarean operations. The foetus not being
viable in these cases, there was no Csesarean delivery as a first stage; and
the second might with as much propriety be named after Schroeder or
Pean, according to the method used, as after Porro, whose process is

1 She Lad at the time a double phlegmasia dolens, and died of cardiac thrombosis.

1883.] Harris, Classification of the Porro Operations. 433

simply a mode of concluding the old Cesarean section. Several of such
cases it is true have recovered, but this does not alter the position I now take,
in claiming that they should be placed in a different classification from
those of the true Porro type.

5. A still different manner of operating was pursued by Dr. Leon
Oppenheimer, of Wurzburg, on July 4, 1880. The patient was 43 years
of age, the subject of malacosteon, and pregnant for the fourteenth time.
Intending to perform an ordinary Mtiller operation, he turned out the
uterus by a long incision, but finding its walls as he thought danger-
ously thinned, feared to make pressure upon the cervix ; he therefore
performed an extra-abdominal hysterotomy, delivered the foetus, left the
placenta in situ, kneaded down the uterus, and when it was well con-
tracted, applied the clamp of Mr. Spencer Wells, cut away the viscus,
and cauterized the stump with a thermo-cautery. This operation took
place in a private house, before labour commenced, and both mother and
child were saved.

This case reminds me of an operation which was performed in this city
on March 5, 1883, at the Woman's Hospital, by Dr. Anna E. Broomall,
assisted by Dr. Albert H. Smith, the consulting accoucheur. Desiring
to avoid hemorrhage, Dr. Broomall turned out the entire uterus ; Dr.
Smith then grasped the cervix so as to control its circulation, whilst she
opened the organ and delivered the foetus, he retaining his hold until the
uterus was well contracted, when it was returned into the abdominal
cavity, its wound sutured, and that. of the abdomen closed and dressed.
Very little blood was lost during the operation, which was not an original
one, except in the substitution of the hand for the elastic tube of Es-
march. The patient of Dr. Broomall, having been exhausted by a labour of
thirty-six hours, died of septic peritonitis in thirty-six hours, a frequent
sequel of wounding a uterus after it has been long under the effect of
muscular action. -The cause of difficulty was a pelvic deformity, the
conjugate diameter of the superior strait measuring two and seven-tenths
inches.

6. Strange as it will appear, after a careful examination of the subject,
statistical collectors still insist in calling a hysterectomy performed after
a laparotomy following a rupture of the uterus a " Porro operation." As
there is no Cassarean section here, there is certainly no propriety in the
title given. The method originated with Dr. Oscar Prevot, of Moscow,
who first performed it, and is entitled to have it called after him., although
there is as yet little honour to be gained from it, as the six cases thus
treated have died. Ear better results have been obtained in the United
States, by either leaving the uterus intact, after removing the foetus and
cleansing the abdominal cavity, or by taking the additional precaution, to*
stitch up the uterine rent.

No. CLXXII Oct. 1883. 28

434

Harris, Classification of the Porro Operations.

[Oct.

By a careful examination of the several forms of uterine ablation
called by the name of "Potto" we will find the following in order: —

1. The true Porro-Caasarean Section, with the stump of the cervix secured

in the abdominal wound, as directed by its originator.

2. The Porro-Miiller Caesarean Section, with the stump as above.

3. The Porro-Miiller Caesarean Section, the uterus being opened with

Paquelin's thermo-cautery knife (Chiara of Milan).

4. The Porro-Miiller Caesarean Section, the constriction being made after

the plan of Esmarch, and the stump secured as above.

5. The Porro-Caesarean Section, with the stump ligated, and dropped

into the abdominal cavity.

6. The Miiller Incision ; uterus unopened before ablation ; cervix incised

and stitched up after the manner of Schroeder, and dropped in.

7. The Porro-Caesarean Section, constriction with Esmarch tubing, and

stump dropped in.

8. The Miiller Ablation ; uterus not opened ; stump secured in the ab-

dominal wound.

9. Utero-ovarian amputation after laparotomy for rupture of the uterus

(Prevot of Moscow).
Thus, we have no less than nine forms of operation, some of them
differing very materially from the original, all called by the name of
" Porro," and classified together, although having very different rates of
mortality. It is hardly necessary to claim that this is very unjust to the
originator, and unfair to his operation. If the Porro method is to stand
upon its merits, rated by its proportion of cures, we must in justice
exclude from the record all the cases not strictly deserving of the title.
As it would only complicate matters to make nine orders of cases, I pro-
pose to combine them where this can be fairly done, and thus reduce the
list to four.

1. Nos. 1, 2, 3, and 4 may be classified as Porro cases, care being
taken to designate those in which the uterus was turned out of the abdo-
men before incising it as " Muller sections."

2. Nos. 5 and 7 will form a second class, the distinction being that the
stump of the cervix was not secured as designed by Prof. Porro, but
dropped in, thereby adding very materially to the mortality of the mothers.

3. Nos. 6 and 8 represent a third class, including all the non-Caesarean
ablations of the puerperal uterus, in which the foetus has not yet reached
a viable age.

4. No- 9 constitutes a class by itself. For simplicity we will name the
four classes, viz.,

^ (True Porro operations.
1 Porro-Miiller operations.

2. Puerperal utero-ovarian amputations, with the pedicle dropped in.

3. Premature ablations of the gravid uterus, the foetus not being viable.

4. Prevot's operation, miscalled " Porro."

1883.] Harris, Classification of the Porro Operations.

435

It is just to Professors Porro and Miiller to keep their respective methods
separate, in rating the mortality of mothers and children, although, where
either plan has been adopted in a hospital in a series of cases, there would
appear to have been a nearly similar result ; as, for example, in the Porro
operations of Santa Caterina, Milan, and the Porro-Miiller operations of
the Allgemeine Krankenhaus, Vienna. It has been stated recently that
the Porro operation is falling off in respect to its proportion of mothers
saved, when the fact is, that just the contrary is known to be true, by
those who write from knowledge, and not from conjecture, based upon
the few reports that appear in our leading journals. The reports that
have come to me of operations thus far performed in this current year
(14), show a recovery of 9, or more than 64 per cent, for all countries.
Prof. Porro is now in a position where the prevalence of deformities of
the pelvis will enable him to personally test his method in a few years.
He has adhered very closely to his original design in operating, as have
also his predecessors on the staff of Santa Caterina, except in the instance
where Prof. Chiara used the long incision. Thus far, this hospital has
saved 9 women out of 12, and all of the children. Thus far, also, Prof.
Porro has saved, of his own cases, 4 out of 5.

As an effort is now being made by three several parties in Europe to
collect, respectively, first, the Italian operations ; second, the first hundred
Porro, and Porro-Miiller operations ; and third, all the so-called " Porro"
cases properly classified ; we shall in time be able to state authoritatively
what has thus far been done by the advocates of the Italian method.
These three papers are in the hands of parties who have successfully per-
formed the Porro operation ; and the last will, no doubt, from the pains
and trouble taken by its author, give us a more reliable and accurate
tabular record of all the cases, than any monograph we have yet examined.
Being fully conversant with the errors of his predecessors, it will be the
aim of the author to avoid them. Personal experience in this kind of
work leads me to commend the zeal of him who is willing to do the
drudgery which, to be accurate, will be required of him. Of all the
different orders of operations that have been styled " Porro," I have a
tabular record of 127, of which 14 have been performed since Jan. 1,
1883.1 It would look like a simple matter to ascertain the accuracy of
the reports on which this table is based, and to fill up the points omitted
by their authors. I did this once, with a much shorter record, and am
very willing now to let another take up the work where I left off, and get
• the credit which is justly due him.

1 Since this paper was in type, I have received the voluminous and carefully pre-
pared record of Dr. Clement Godson, of London, which gives of my first and second
classes combined, 129 cases and 71 deaths ; of the third class, 5 cases with 2 deaths ;
and of the fourth, 6 cases with no recovery. The dropped pedicle cases are 13 of the
129, and 11 were fatal. Exclude them, and we have 116 operations of my first class
with 56 recoveries. The whole record of Dr. Godson, 116 + 13 + 5 + 6, is 140 cases,
with 61 women and 102 children saved.

436 Harris, Classification of the Porro Operations. [Oct.

We have had in this country six puerperal utero-ov avian amputations,
commencing with the case of Storer in 1869. Of these six, all were
fatal to the mother but one, viz., that of Richardson in 1880. Five of
the six cases were operated upon in private houses ; the exceptional one
being the last, that of Dr. Parish, at the Philadelphia Hospital, on June
29, 1883. In one case the foetus was non-viable; in two cases it was
dead, and in three it was saved. In not one of the five operations which
date since that of Porro, in 1876, was his method entirely carried out.
In three cases the modification of Miiller was preferred ; and in two,
although in other steps " Porro operations," the stump was ligated and
dropped in. Thus far the adoption of hysterectomy in some of the
Cesarean operations of the United States has given no advantage in a
decreased mortality, as compared with the old method. In 1880, the last
year of which I have a full report, there were o old Cesarean opera-
tions, saving 3 women and 4 children. The time in labour was re-
spectively, four days, sixty hours, thirty-two hours, thirty hours, and
three hours, the last being the only elective case. Of 18 old Cesarean
operations known to have been performed in our country since the new
method was introduced into Italy, there have been but four that were
performed early, and of these, two were successful. One case that was
lost was in extremis from ante-partum hemorrhage at the time of the
operation ; the other had a large pelvic tumour, and died of septicaemia.
Our estimation of the Porro operation is based entirely upon the com-
parative records of the old and new methods in the maternity hospitals of
Europe. In the United States, where the Cesarean operations are usually
in private houses, the mortality under the old method, when elective and
performed early, has been only from 25 to 30 per cent. Three Porro
operations have been performed prior to the commencement of labour,
with a loss of two cases. The plan is therefore still on probation with us.
As the six old Caesarean cases in hospital in our country all died, it will be
well in the future to follow the example of Dr. Parish, and try whether
the Porro method will not be less fatal in its results in hospital materni-
ties here as it has been in Italy, France, and Austria.

Appendix The valuable monograph of Dr. Godson, already referred

to, which is a marvel of painstaking research and accuracy, enables me
to present the following analysis, carefully prepared and computed from
his tables, which cover nineteen quarto pages : —

1883.] Harris, Classification of the Porro Operations.

437

438 Harris, Classification of the Porro Operations. [Oct.

1. " True Porro operations," with the pedicle kept out, 82. Of these
cases, 44 died, and 38 recovered. Children removed alive, 64; still-
born, or moribund, 19; one woman, having twins, removed in a dying
state ; she was also lost.

2. Porro-Miiller operations (the uterus being turned out before opening
it), with the pedicle kept out, 34. Women saved, 18 ; lost, 16 ; children
removed alive, 26 ; dead, or moribund, 9. One woman bore twins, which
were saved, but she was lost.

3. Modified Porro operations, the pedicle being dropped in, after the
ablation of the uterus, 8. Women lost, 8 ; children alive, 7 ; dead, 1.

4. Modified Porro-Miiller operations, the pedicle being dropped in, 5.
Women saved, 2 ; lost, 3 ; children living, 5.

5. Premature ablations of the gravid uterus (the organ not being
opened, the fcetus not viable, and the pedicle being kept out), 4. Women
saved, 3 ; lost, 1.

6. The same, with the pedicle dropped in, 1. Woman lost.

7. Prevot's operation (the uterus being removed after laparotomy, fol-
lowing the rupture of the organ, and the pedicle kept out), 5. Women
lost, o ; children lost, 5.

8. The same operation, with the pedicle dropped in, 1. Woman and
child lost.

After the initial operation by dropping in the pedicle, in 1880, was per-
formed, there were six more in imitation of it within six months, all fatal
but the seventh. There was one only in 1881 ; but in 1882 there were
four, and there was one again in January of this year. The fact that the
seventh and thirteenth cases were the only ones not fatal, should make
surgeons hesitate in adopting Veit's method. Operators may be tempted
to treat the stump, as they do the pedicle in a large proportion of ovari-
otomies, but they should know what is taught by the failures of those who
have tried it in the past.

Thus it appears from the above record, that the Porro operation, car-
ried out as originally designed, has saved 46i* per cent, of the cases ; the
Porro-Miiller method, unmodified, has saved 52i| per cent.; and the two
combined, 48¥8¥ per cent, of the women, and 90 out of 118 children.

The 116 Porro and Porro-Miiller operations have been performed in
the following countries, viz.: Italy, 48; Austria, 25; Germany, 15;
France, 12 ; England, 4; Belgium, 4; Switzerland, 2 ; United States, 2 ;
Russia, 1 ; Holland, 1 ; Spain, 1 ; and Turkey, 1 = 116.

The cases of dropped pedicle are distributed as follows : Germany, 6 ;
Austria, 3 ; United States, 2 ; Italy, 1 ; and Scotland, 1 = 13.

The chief operators* counting all their forms of incision and treatment,
are Professor Carl von Braun-Fernwald, 11, saved 8, and Professor Gus-
tav Braun, 6, saved 2, both of Vienna. Professor Domenico Chiara, of
Milan, o, saved 3. Professor Edoardo Porro, of Pavia and Milan, 5,

1883.] Michel, Ligation of the Subclavian Artery.

439

saved 4. Dr. Girolamo Previtali, of Bergamo, 5, saved 1. Dr. Heusner,
of Barmen, Germany, 4, saved 0. Dr. Just. Lucas-Championniere, of
Paris, 4, saved 2. Professor Domenico Tibone, of Turin, 4, saved 1.
Professor August Breisky, of Prag, 4, saved 4. Professor S. Tarnier, of
Paris, 3, saved 1 ; and Professor Josef Spath, of Vienna, 3, saved 2 = 28
women saved out of 54. Of the 26 cases lost, there were 5 in which the
pedicle had been dropped in.

The record of Italy, kindly sent me by Dr. Domenico Peruzzi, of Lugo,
shows that they have had in that country 43 Porro operations, with 20
women saved ; 5 Porro-Muller operations, with 2 saved ; 1 Porro- Yeit
operation (the pedicle dropped in), woman lost; and 2 modified Prevot
operations after ruptured uterus (the pedicle dropped in), both women lost.
329 S. Twelfth St., Philadelphia.

Article YII.

Ligation of the Subclavian Artery between the Scaleni for Hem-
orrhage from a Gunshot Wound. Recovery. By Middleton
Michel, M.D., Professor Medical College, South Carolina, Charleston, S. C.

The case, whose history we shall furnish at some length, will be found
to exhibit an exceedingly rare cause of hemorrhage from gunshot wounds,
recognized by some, though scarcely referred to by systematic writers on
surgery ; as when an artery in the vicinage of a shot-wound loses its
vitality at the time of injury, through shock, and, subsequently, more com-
pletely through prolonged contact with morbid products in the contused
and lacerated wound, shares in the general disintegration of the surround-
ing structures, and yields, in the course of time, to blood-pressure, giving
rise to the rarest form of hemorrhage, and from its suddenness, to the most
alarming and dangerous.

The aspect of the subject from this pathological standpoint acquires im-
portance, especially to the military surgeon, as such a rare factor imported
into the history of a gunshot wound will have much to do in directing his
judgment and influencing his decision in granting furloughs predicated of
a supposed cure, or of a progressive convalescence.

We are led naturally to take this view of our subject since the follow-
ing case occurred during our connection with the wounded of our army in
Richmond, Yirginia, and though immediately reported to the department
by myself, and generally talked of among the surgeons at the Capital, has
been incorrectly reported in the pages of the valuable volumes on the
Surgery of the War, emanating from the Surgeon-General's Office in
Washington.

440

Michel, Ligation of the Subclavian Artery. [Oct.

With regard to this particular case, which follows, I may be permitted
to say that, when surprise, which is ever sudden, and alarm, which is
always associated with hemorrhage from a large vessel so near the heart, are
accompanied with the difficulties of the unpremeditated operation required
for the patient's safety, one can readily understand the interest it created
at the time among the surgeons at the Capital. This interest, again, is
enhanced by the simple history of the case, since, of all the varied causes
of hemorrhage which could possibly arise from so remote, so unfore-
seen, so accidental a cause as some obscure and seemingly spontaneous
invasion of only one point in the walls of a vessel through the sluggish
eliminative process of a slough from the shot-passage, this is so remarkably
rare, that it scarcely occurs, on an average, more frequently than once in
two or three thousand instances of gunshot wounds of arteries ; indeed, a
precisely similar instance was unknown to me from any source throughout
the Confederate army, at a time in which I was more or less engaged in
consulting almost every official report in the department, through the cour-
tesy of Dr. Samuel Preston Moore. The rare occurrence of a local injury
precisely where it must involve surgical interference in the course of one
of the largest, yet least accessible, of the vessels of the body; and the
ultimate success of a procedure contravening the established rule of local
deligation in such emergencies, owing to prohibitory conditions of the
vessel-walls; with the strikingly large mortality of from 70 to 80 per
cent, in all ligations of the subclavian under any circumstances, and at
any part of its course ; are some of the particulars which surround this
case with more than common interest.

As I review the past, at this late date, it seems ominous that in
crowded wards, where once lay the mangled bodies of so many suf-
fering and dying men, whose claims upon our untiring devotion were
imperative, yet whose histories hold no special place in our memory now,
there was one whose comparatively trivial wounds seemed then to call
for nothing more urgent than the accommodating attention to his fur-
lough papers, who yet was destined to become more memorable than any
of his companions in arms in fixing even his name, as well as the story of
his injury, indelibly in our minds. This history, then, may be said to
recall the most conspicuous surgical event perhaps resulting from those
memorable engagements at Chancellorsville, in which the wounded on
both sides numbered 18,000, while no less than 3000 men were killed : —

It was, then, on the 3d of May, 1863, that G. M. Coughman, corporal,
Co. K, 13th Regiment of South Carolina Volunteers, aged about 25 years,
received his wound from a Minie ball, which entered midway between the
vertebral border of the left scapula and spinal column, coursed apparently
upward, forward, and to the left, making its exit about two-thirds of an
inch below the middle part of left clavicle. There was no primary hemor-
rhage. Subsequent and oft-repeated hemorrhages from nose and mouth
were sufficient to indicate that the pleura had been opened, and the lung

1 883.] Michel, Ligation of the Subclavian Artery.

441

wounded. Haemoptysis continued from time to time, gradually diminish-
ing until it ceased entirely. Coughman reached Richmond, Virginia, and
was admitted into the Manchester Hospital, under my charge, on the 14th
of May. His wounds claimed but simple dressings, as there was not more
discharge than is wont to occur from such an injury. Absolute rest and
decubitus were enjoined, and the cough, which was at first troublesome,
having been soon controlled, the subsequent treatment consisted in simple
attention to the wounds, which steadily progressed so favourably that in a
short time the orifice of entrance in the back completely healed, and the
wound of exit below the clavicle had so far closed as to require only a
dossil of lint to protect his shirt from the slightest discharge. With re-
turning health and strength he naturally sought to obtain a furlough, which
official papers, through recent orders, required to be sent to the field for
the signature of General Lee. The delay which this entailed, and long-
deferred hope, annoyed him greatly, and it was said that, on permit, he
would walk to Richmond again and again to ascertain the fate of his
papers ; a fact which is here mentioned, as I subsequently learned that
it had often been surmised that his health was restored' to such a degree
that by the time his furlough could be obtained it would be of no avail
to him, since, upon an inspection, he would be pronounced well, and
would, doubtless, be returned to duty.

On the 2d day of June, I chanced to be detained the entire day at
the hospital, not returning to Richmond as usual at two o'clock, when, in
the afternoon, I accompanied one of my resident surgeons, Assistant Sur-
geon Seabrook Jenkins, in his second visit through his wards. We had
nearly gone the round when a commotion and alarm in the ward admon-
ished us that something was wrong on the opposite side, where the nurses
were endeavouring to suppress hemorrhage in one of the patients by com-
presses held down upon the chest. We discovered that it was Coughman,
seized with a violent fit of coughing, who was bleeding most alarmingly
from the wound beneath the clavicle. Arterial blood issuing per saltum
in so rapid a stream permitted of no delay. J instantly forced my
index finger with some difficulty into the wound, breaking through the
partly organized, though softened, granulations of the bullet-track, which
immediately arrested the hemorrhage. The patient's alarm was ex-
hibited by the beatings of the carotids ; I took occasion to assure him
that he could bleed no more, that my finger acted as a cork in a bottle ;
and I requested Surgeon Jenkins to prepare what was necessary for the
ligation of the subclavian. Chloroform was administered, and as I re-
moved my finger Dr. Jenkins inserted his, thereby controlling again a hem-
orrhage yet more considerable than at first, in consequence of the enlarge-
ment of the wound. Suspecting the artery not sound in the third part of its
course, and that a wound of some depth would certainly be required, ample
room became desirable. Depressing the shoulder, I extended an incision
the entire length of the clavicle immediately above and parallel to that
bone, dividing the structures carefully upon the groove director; a broad
.clavicular attachment of the sterno-cleido-mastoid required to be divided,
and the external jugular vein was drawn on one side ; the structures within
the supra-clavicular triangle were cautiously lacerated with the blunt end
of the director, which brought the scalenus anticus neatly into view with
the phrenic nerve. The size of my incision permitted me to prosecute the
operation without any vertical incision, and I had the good fortune to
encounter no vessel requiring to be secured, meeting neither the transver-

442

Michel, Ligation of the Subclavian Artery.

[Oct.

salis colli nor humeri vessels. My finger, introduced deeply into the wound,
felt the subclavian artery, and I recognized the tubercle on the first rib, but
finding it impossible to depress the handle of Deschamp's needle so as safely
to conduct the instrument around the isolated vessel, I divided the belly of
the scalenus upon the director, carefully respecting the phrenic nerve,
when I readily conveyed the needle armed with its ligature around a per-
fectly sound part of the artery between the scaleni. We assured ourselves
that the subclavian alone, with no branch of the brachial plexus of nerves,
was included within this ligature; the artery was then tied securely in this
portion of its course ; and when my assistant removed his finger there was
no hemorrhage.

During the progress of this operation we seemed not to have invaded
the cellular tissue at the apex of the lung, the continuity of which, with
the mediastinum and thoracic fascia, places us here on the border of the
chest, in a stratum of usually very loose tissue, conducting inflammation
with its products readily, surely, and dangerously to pleura and pericar-
dium ; indeed, the tissue here, beneath, beyond, and around, appeared
condensed through the probable deposit of organized fibrin during the pro-
longed reparative stages of healing throughout the shot-track. The greater
part of our incision was now united by sutures and promptly healed with-
out any untoward symptom, the ligature coming away somewhere between
the twentieth or twenty-fifth of June ; the precise date J cannot now state,
as the operation was performed just prior to his transfer to the Alabama
Hospital, in Richmond.

I am ready to confess that, from the general experience with gunshot
wounds which, in common with many of our surgeons, we had surely
acquired, I looked upon the operation at the moment as only of temporary
advantage, expecting, in due time, to witness secondary hemorrhage from
the distal end of the vessel. This accident, however, never occurred ; on
the contrary, this soldier made a rapid and perfect recovery, for, up to the
day and hour when I last saw him, he was the constant object of jealous
interest to me, and remained perfectly free from accidental complications.
I should here state that none of us recognized any indication of the
paralysis to which reference is made in the report of this case,1 in which
the reporter complacently hints that it was possibly due to some branch
of a nerve of the brachial plexus included in my ligature.

There was no more numbness of the limb, nor stiffness of embarrassed
motion, than is met with usually after cutting off the main supply of blood
to a part ; while a prolonged immobility of the limb, on which I had
urgently insisted so as to avoid all possible tension or strain upon the
vessel, would of itself, from the stiffness ensuing, have imposed the belief
upon some inattentive observer that this is what is called paralysis. As
was well known to those around us at the time, Coughman left with no
such symptom, when, in obedience to an official order, he was transferred
temporarily, with all the wounded and convalescent, to the Alabama Hos-
pital in Richmond. . . .

1 Surgical History of the War, Part I., vol. ii. p. 538.

1883.]

Michel, Ligation of the Subclavian Artery.

443

The history of this most rare case is pregnant with instructive admo-
nitions, especially to the military surgeon. Engaged as he 'so often is in
determining the safety or clanger attendant upon granting furloughs in
particular instances, it appears a most important lesson to learn, that
the vicinity of a large bloodvessel to the track which a ball has tunnelled
through the tissues makes it difficult to declare, until the wound has com-
pletely healed for a time, whether or not the main artery is threatened
with any anticipative or subsequent danger. Had Coughman's furlough
reached him earlier, this appalling hemorrhage must have occurred while
upon his journey ; yet hundreds with wounds not nearly so well as his
were daily on their route homeward. How difficult to defer our decision
upon so remote a possibility, where no primary or secondary hemorrhage
indicates direct injury of the vessel ; still, we must remember that there
is a remote hemorrhage, scarcely to be expected, a kind of spontaneous
dehiscence of the wall of an artery dependent upon the removal of all sup-
port against the blood-wave through the slowly softening and molecular
disintegration of an infiltrated and ulcerative, or broken-down point ; rare,
indeed, in a vessel of the magnitude and importance of the subclavian,
though so familiar to us all in the attenuated capillaries along the walls of
tuberculous pulmonary caverns.

It was this special cause of hemorrhage as here described, so wholly
different from that arising from spicules of bone, from fragments of clothing,
from ball, or from any other foreign body, pressing upon, lacerating, or
temporarily occluding the blood-channel, which makes this case of sub-
clavian hemorrhage almost unique.

I cannot refrain from calling attention to the pertinent reflections of the
late distinguished compiler and annotator of the surgical statistics of the
war — Asst. Surgeon George A. Otis — who opens his remarks on lesions
of the subclavian artery and vein thus : —

'; Wounds of these great bloodvessels occasionally come under the surgeon's
treatment. It is quite time that the dictum of Jourdan that surgery is powerless
in lesions of arteries within the cranial, thoracic, and abdominal cavities should
be expunged from the text-books. At least five cases occurred during the late
war, of wounds of the subclavian, in which surgical intervention was justifiable,
and in one of these the left subclavian was successfully tied by a Confederate
surgeon, for a ivound of the vessel where it passes across the first rib. Though
such lesions are immediately mortal in the majority of cases, there are instances
in which the bleeding is delayed or arrested, the laceration of the artery being
obstructed by spicule of bone, or by the missile, or a fragment of clothing, or
other foreign substances. In such cases audacity is the part of prudence."1

1 Surg. Hist, of the War, Part I., vol. ii. p. 521. In the above quotation the italics
are my own. With Dr. Otis I must express regret that, with official documents before
him, Dr. Thomas should, in his report of this case, misspell the patient's name, omit
date and name of battle, and date of injury, withhold the surgeon's name who operated,
yet go on to state that paralysis existed, and to surmise that some nerve must have
been included in my ligature.

(

444 Michel, Ligation of the Subclavian Artery. [Oct.

Another important feature in this case, not, however, without a parallel
in my own personal experience, is the successful application of Ariel's
method to so large a vessel. The known mortality in ligations of the
subclavian artery, excluding pleural, gangrenous, orpyaemic complications,
is due to shortness of clot, to numerous collateral branches of large size,
and, as I have always believed, to strain or tension upon the vessel in
movements of the arm.

This mortality is stupendous, for more than half die in very short
periods after the operation, in consequence of recurring hemorrhage from
the distal end of the vessel. While such discouraging results would
appear due to neglect of the accredited rule of Guthrie, by the defection
of some surgeons, yet, as Dr. Otis properly remarks,1 " the difficulties in
dealing with gunshot wounds of the clavicular and axillary regions are so
great as often to defy the best planned and most skilfully executed surgical
interference ; and those whose experience of traumatic lesions of the sub-
clavian and axillary regions is largest are least hasty in criticizing failures
in their management."

It is not impossible, nay, it is even most probable, that the histogenetic
work of repair throughout this wound, together with consentaneous
changes in the walls of the artery, may have obliterated the distal
portion of the subclavian so as to deflect the circulation into collateral
channels, enlarging the many anastomoses, preparing in advance for the
ultimate fulfilment of our purpose. This hypothesis would explain the
success of my operation, for secondary hemorrhage may be said to occur
nearly always from the peripheral end of an artery on account of the im-
perfect clot. In no other way do I account for the absence of recurrent
hemorrhage. That such obliterations in the calibre of the largest vessels
are possible where the vessel has never sustained more than " shock," so
to speak, is amply testified to by several necropsic examinations that have
been made. Holmes, referring to this subject, says : "About contusion
of arteries little is really known. It seems undeniable that contraction
and even total closure of the artery may follow on mere contusion, and
that this may be a cause of gangrene. So Guthrie relates a case in which
a bullet passed between the popliteal artery and vein without opening
either. Gangrene ensued, and the man died. i The coats of the artery
were not destroyed in substance, though bruised ; it was at this spot much
contracted in size, and filled above and below with coagula.' "2

Some years ago, a white man, Mr. Savage, acting as an overseer on
Dr. Keith Furman's plantation, on Daniel's Island, received a stab-wound
which compromitted the brachial artery just in the neighbourhood of the
origin of the superior profunda ; the wound was immediately closed with
stitches, and a firm compress applied with bandage. Strange to state,

1 Surg. Hist, of the War, Part I., vol. ii. p. 557.

2 T. Holmes's Surgery, Am. ed. 1876, p. 107.

1883.] Michel, Ligation of the Subclavian Artery.

445

the wound in the arm, or skin, healed very promptly, but a traumatic
aneurism necessarily ensued. Dr. Furman sent him to the city to me,
requesting me to operate. In this instance, though but a few days after
the receipt of the injury — in a comparatively fresh wound — in a clear
case of pulsating traumatic aneurism of the brachial artery, I nevertheless
ligated the axillary in the deepest part of its course in the armpit ; the
pulsations in tumour immediately ceased, no recurrent hemorrhage ensued,
and the recovery was rapid and complete. Here again the Hunter, as
above the Anel, method succeeded perfectly. I can but regard success
in so recent an injury as an exception to the accepted rule of practice,
which it would not be wise always to follow, nor would I have myself
pursued precisely this course, but for the expression of the opinion of my
colleagues at the time as to the possible condition of the vessel above and
below the aneurism.

The minute history which I record forbids my pretermitting some refer-
ence to the pulmonary difficulty here involved. Can we lose sight of the
frequent hemorrhages from nose and mouth, and the obstinate and trouble-
some, and, it may be added, almost fatal, cough, which ultimately dis-
lodged the slough or ruptured the attenuated wall of this artery? For
some time after Coughman fell wounded at Chancellorsville he continued
to suffer from what the field-surgeon reported as haemoptysis, and, though
I never witnessed an attack of veritable haemoptysis after he came under
my care, yet expectoration of mouthfuls of blood and bloody saliva, the
result of a constant cough, is well fixed in my memory, for this was about
the only symptom for which he was occasionally treated by Dr. Jenkins.

We step upon debatable ground when we are willing to take any single
symptom as pathognomonic of lung-wound, for neither hemorrhage,
dyspnoea, traumatopnoea, etc., nor even auscultatory revelations, are
sufficient to establish clearly a gunshot lesion of the pulmonary tissue ;
yet the subsequent rupture of the subclavian, which actually indicated
the transit of the ball in a direct line from point of entrance to exit,
certainly proved that the pleura must have been opened and the lung
wounded, independently of any pulmonary symptom. Even if we in-
dulge the missile in the most eccentric deflections around the thoracic
cage, it seems to me impossible that this artery could thus have suffered.
This pulmonary wound was followed, however, by no serious complica-
tions, for there was neither traumatic pleurisy nor pneumonia ; abscess
nor effusions ; though pleurisy is so likely to follow chest-wounds where
. the ball has never penetrated the pleural cavity, nor even wounded the
pleura. Here, then, again, is an important point in the case. Recovery
under these circumstances might very well surprise us had we not been
familiar with wonderful recoveries after the most serious injuries of the
lung ; one of the most marvellous, perhaps, of which was brought before our
Association of Army and Navy Surgeons by Dr. W. G. Thorn, a synoptical
but full report of which, from my pen, was published in the Confederate

446

Michel, Ligation of the Subclavian Artery. [Oct.

States Medical and Surgical Journal for April, 1864, and copied into
the second volume of the Surgical History of the War, page 597. In
this instance the pleura and lung were terribly wounded, and an English
patent-lever watch, with portion of its accompanying chain, etc., was
driven into the chest. Imbedded in the lung for some time, during the
process of granulation, while dressing this wound, the watch was discovered
by its metallic lustre, when the greater part, together with the links of
the chain, was removed, the wound gradually healed, cough continued,
and in course of time the patient expectorated all the small works of the
watch, which are said now to be in his possession. As severe an injury
as this well-attested example affords was nevertheless unaccompanied by
any of those reasonably-to-be-expected pathological sequels of which we
have spoken above, at least not to a fatal extent.

If we have dwelt tediously, it may be, upon Coughman's case, it has
been because we believe that any reflections upon attempts at occlusion of
the subclavian artery by ligature, and the results which may have followed
the operation, present at once a subject of momentous interest to the
surgeon on account of the rarity of the event. Dr. T. G. Morton, of
Philadelphia, tells us that at the Pennsylvania Hospital between the years
1835 and 1868 the subclavian had been tied but once, with a fatal result.1

The operation is rare per se, and the special condition to which we
have called attention is still more so. In certain instances where it is
said to have been done, the circumstances influencing the result will be
found to be wholly different, as where the vessel has been tied for an an-
eurism, which may of itself have secured all danger from distal hemor-
rhage ; or for some lacerated wound from a railroad accident which has
torn away the shoulder, and the artery in its extreme third portion of its
course is picked up with a tenaculum and secured to save the patient from
dying immediately. How great must have been the immortal fame of
the illustrious American, Valentine Mott, of whom Dr. Gross says, "No
surgeon, living or dead, ever tied so many vessels, or so successfully,"
when we learn that he ligated this vessel alone eight times ! During the
Franco-German War, Prof. Billroth performed the operation three times,
and saw it executed twice by other surgeons, yet of these five ligations
during that war one only of these patients is believed to have ultimately
recovered.

With no more appropriate words can I close these remarks than with
those of Dr. Otis : " Since the achievement of Dr. Billroth and others
in the recent Franco-German war, I am led to regard the management of
wounds liable to involve the great vessels at the upper part of the chest
as perhaps the most important field of study for those who occupy them-
selves with questions of what the French term la haute chirurgie.,>

Charleston, July, 1883.

1 Am. Journ. Med. Sci., April, 1876, p. 334.

1883.] Chambers, Galvano-Puncture for the Cure of Aneurism. 447

Article VIII.

Galvano-Puncture for the Cure of Aneurism. By T. R. Chambers,
M.D., of East Orange, N. J.

Tins operation deserves more recognition in this country than it has
obtained.

The following experiments were undertaken in the study of the subject.
The case reprinted is from the Bulletin of the New York Pathological
Society} Perhaps the adverse criticism which it has received may not
seem quite justified when attention is called to certain points in the case.

An albuminous fluid held in the palm of the hand was subjected to the
influence of a galvanic current from twenty-one cells of a Stohrer battery.
Two needles acted as poles. Great electro-chemical action took place.
There was no pain, notwithstanding the proximity of the poles to the skin,
as long as they did not touch it.

A sheep's gall-bladder was thoroughly washed out. Two short glass
tubes were fastened in openings made in it, opposite each other. One of
the glass tubes was connected with the carotid artery of a healthy calf and
its blood was diverted into the collapsed gall-bladder, which, when it be-
came distended, pulsated like a real aneurism. The escape of blood from
the bladder was controlled by sufficient digital pressure upon a rubber
tubing attached to the second glass tube to simulate the condition of ob-
struction existing in the exit of blood from the aneurismal sac. This
imitation aneurism, 8xoxo centimeters in size, pulsated for five minutes
fed by the blood of the calf s carotid. It was then disconnected and imme-
diately opened — it contained no coagulation.

A bladder similarly arranged was connected with a calf's carotid, and
when it began to pulsate, a needle insulated for half its length was plunged
into its interior. This needle became the positive pole of a twenty-one
cell galvanic current, while the negative pole was applied by coils of wire
externally. The current was continued for five minutes when the bladder
was disconnected as before and immediately opened. The needle was found
in the centre of a firm, hard coagulum 3 x 2 x 1.5 centimeters in size.

Another calf was taken and both poles were introduced into the pulsating
bladder arranged as before. The result was unsatisfactory; froth, gas, and
tar seemed to be generally commingled when the bladder was cut open,
though there was some firm substance about the positive needle.

Then in still another bladder two needles were introduced and the
current alternated, with a like unsatisfactory result.

From these experiments, I think, an idea of the relative value of the
different methods employed may be gathered. Of course there are many

1 Volume for April — November, 1831.

448 Chambers, Galvano-Puncture for the Cure of Aneurism. [Oct.

objections in likening these crude imitations to the true aneurism as it
occurs in man. Yet, if nothing more, it shows that the positive needle
only should be introduced into the tumour. The pain is only what occurs
with the prick of a pin.

Suppose the current of blood in an aneurism could be stopped by distal
compression for fifteen minutes or longer, and the positive pole inserted
for five minutes in three or more different places, does it not seem impos-
sible for the sac to escape entire consolidation ?

The results obtained agree with the conclusions of Robin, quoted here-
after.

The following case, presented to the New York Pathological Society,
is published at this time because unfavourable criticism of the operation
has appeared.

The man was apparently about to die, and desired to try galvano-

puncture in the full knowledge of
our inexperience in this country.
The operation, notwithstanding
the alternation of poles, no one
can say hastened his death an
hour. He lived four months and
a half after it, and during three
mouths of this time was in com-
parative comfort, many of the dis-
tressing symptoms disappearing.
This fact remains whether post or
propter hoc. The author be-
lieves with others that if the posi-
tive polealone had been introduced
as before suggested, cure would
certainly have resulted, and the man spared to a life of usefulness. The
accompanying figure is a very nearly true representation of the pathologi-
cal condition of affairs during the last week of the man's life. It shows
an immense tumour quite as large, if not larger than the unhypertrophied
heart; the places of pouting ; the inclusion of the first and second ribs and
clavicle ; the atrophied arm.

Andrew J. W., United States, aged fifty-three, married, a printer.
Inheritance and habits good ; no syphilis ; one attack of rheumatism, last-
ing one month, in his ankles, about twenty years ago.

The first symptoms of aneurism began three years ago with pain in the
little finger of his left hand, and gradually extended into the arm and
whole upper extremity. In January, 1880, the subclavian aneurism had
become a prominent tumour upon the left side of the neck, with visible
pulsation, thrill, and bruit. The pain was chiefly referred to the upper
extremity, scarcely any being felt in the tumour itself. Iodide of potash
had been administered during the past year, continuously. At times large

1883.] Chambers , Gal vano-Puncture for the Cure of Aneurism. 449

quantities of morphine were necessary, and occasionally his mental dis-
quietude required the addition of a mixture of chloral and camphor, equal
parts ; which proved of great service for disturbed sleep, and calmed his
maniacal tendencies. Dr. R. F. Weir examined the patient and found a
continuous bruit across the manubrium sterni, that did not seem to be car-
diac ; but which, together with the patient's complaint of pain in the cervico-
dorsal spine, led him to suspect dilatation of the arch of the aorta. The
cardiac physical signs failed to reveal any pathological changes. The trac-
ing of the left radial pulse, obtained with great difficulty on account of the
smallness of the current, yielded the usual wavy descent found with ob-
struction along the course of an artery. In March, there was oedema of the
left upper extremity, as well as of both ankles, and the doses of morphine
had reached the enormous quantity of thirty centigrammes in a .single day.

On March 30th, he had a sudden attack of dyspnoea, and for two weeks
was compelled by weakness to remain in his chair, being unable to walk :
dorsal decubitus was uncomfortable. On April 23d, he had a chill and
fever, with abdominal pain and swelling ; and the same symptoms were
repeated on May 31st, when the abdominal swelling assumed quite an
extensive size, requiring surgical interference to evacuate a cupful of pus,
from an abscess in the abdominal wall.

On May 19th, a plaster cast was taken of the shoulders and neck. There
was a large tumour rising above the left clavicle, between it and the tra-
pezius behind ; bounded externally by the acromial end of the clavicle,
and rose internally almost to the border of the inferior maxilla.

There were at no time symptoms of pressure upon the trachea or carotid,
but only signs of compression of the nerves of the left cervical plexus and
of the veins of the same region, together with a diminished blood supply.

Oct. 8. The aneurism has slightly increased in size and shows a ten-
dency to pointing; and the pain in the region supplied by the brachial
plexus has become so excruciating that the patient wished to try any-
thing (!) to relieve his sufferings.

Needling} — Six milliner's needles four and a half centimeters long
were introduced, and on the next day nine more were inserted into the
tumour, care being taken to avoid the direct blood current. Some of the
needles gave slight pain on piercing the skin, others none. After remain-
ing imbedded in the tumour for six days, the needles were removed ;
there was no apparent change in the aneurism.

2-ith. There is visible pulsation and expansion in every available
part of the tumour. A thrill is felt posteriorly adjacent to the neck, and a
distinct bruit is heard everywhere, especially over the region of the thrill.
The blood current approaches the surface in several places, and very
threateningly at points of pouting.

Galvano-punctnre. — With the kind advice and assistance of Dr. E.
Evetsky and Dr. G. L. Knapp, galvano-puncture was resorted to. The
apparatus employed was a Stohrer's battery of twenty-one cells ; a rheo-
stat by which the intensity of the current could be gradually raised or
lowered between a single couple and the full strength ; and six milliner's
needles, eight centimeters long, with their points changed to sharp, flat-
tened spear-heads ; the latter were insulated by collodion, which increased
their size from No. 2 to No. 4, French. Three centimeters of polished
steel of the needle were to be exposed in the tumour.

1 See Heath on this operation, Lancet, January 31, p. 168.
No. CLXXII.— Oct. 1883. 29

450 Chambers, Galvano-Puncture for the Cure of Aneurism. [Oct.

First seance The patient being etherized, two needles were inserted

parallel to each other, two centimeters apart ; then a strong galvanic cur-
rent was passed through them and the poles alternated every h've to eight
minutes. They remained inserted about forty-five minutes. When
withdrawn a peculiar black -and-blue appearance of the whole upper ex-
tremity was noticed. One of the needles had lost its exposed steel, which
had been utterly consumed, not broken off — an accident which has hap-
pened to some experimenters ; the other needle was rough, black, and
thinned. Their removal was accompanied by the escape of gas and tarry
fluid. The patient passed pleasantly out of the etherization. Slight
change in the shape of the tumour was observed ; the thrill was dimin-
ished ; and there was a seeming condensation of the contents of the aneu-
rism beneath one of the punctures.

For four days there was no change noticeable in the tumour nor in the
patient's condition, which was very good.

Second seance — Oct. 29. On this occasion it was with considerable
difficulty the patient was etherized. The current passed through two
needles inserted as before. Within five minutes of starting up the cur-
rent, a scarlatinoid rash appeared on the left shoulder and upper extremity,
and gradually darkened and became black and blue in irregular patches.
The thrill disappeared. On withdrawing one of the needles, a subcuta-
neous hemorrhage at the puncture occurred, forming a secondary haema-
toma almost as large as the aneurism itself, but pressure finally controlled
it. After fifteen minutes' interval, two fresh needles were introduced in
other places near the thin parts of the sac, and the current was passed as
previously described, alternating the poles every five to eight minutes,
until the whole seance lasted forty minutes. On withdrawing one of the
needles, a bright arterial stream spurted out of the puncture, but this was
soon controlled by pressure.

The patient did not come out of the etherization, but went into a state
of coma, from which he only partly emerged two days later, but with ex-
ternal strabismus and almost constant nausea and vomiting. For four
days after, there was severe headache and complete loss of vision even to
recognition of light. The black and mottled appearance of the arm gradu-
ally disappeared at the end of a week ; and blebs, which had formed upon
palmar surfaces of the second and ring fingers, gradually dried up after
two weeks ; ecchymotic spots scattered over the arm and hand also dis-
appeared.

With the exception of these two weeks, for three months after the ope-
ration there was a great amelioration of the symptoms, so that the patient
only had to take an occasional dose of morphine. During the latter part
of February, 1881, the pain in the tumour became very severe; formerly
the pain had been confined to the shoulder, arm, and hand.

March 6 {four months and ten days since the galvano-puncUire opera-
tion.) The tumour attained to the size of a baby's head, and had three places
of pouting where the sac wall was scarcely the thickness of paper. His
body was constantly bathed in perspiration ; his mind wandered ; vision
was completely lost ; but hearing was very acute. He refused to swallow
any nourishment, lest in the effort the aneurism should burst ; but at
2 A. M. the upper place of pouting gave way while the patient was at
stool, the blood squirted across the room and struck the opposite wall, and
oozing continued for four hours, notwithstanding the pressure applied.

On March 9th, a second rupture occurred from another place of pouting,
and oozing lasted for half an hour.

1883.] Chambers, Galvano-Puncture for the C ure of Aneurism. 451

On March 10th, a third hemorrhage from a re-opening of the upper
place of pouting occurred, and it required digital pressure for an hour and
a half to stop it.

14?7?, 12.30 A. M. Patient was drawn up in bed for half an hour
by agonizing pain in the tumour, when suddenly his pain was relieved
and he died quietly. There was a slit two centimeters long in the upper
anterior part of the tumour.

Autopsy, twelve hours after death.

Body not emaciated ; features placid ; no oedema. There is a depres-
sion in the suprascapular region, where the tumour had existed ; and the
left upper extremity was atrophied.

Abdomen. — The subcutaneous adipose tissue was abundant. The mus-
cular layers on the right of the median line, where the umbilical tumour1
had presented, were thinned. Peritoneal adhesions over a surface an
inch square anteriorly upon the right lobe of the liver ; none elsewhere.
There was injection and slight thickening for a space the size of the palm
of the hand at the site of the abscess in the right lumbar region. Vermi-
form appendix normal ; intestines also.

Thorax. — No adhesions ; there were no signs of pressure upon the
sternum or the spine. Heart, in normal position, firmly contracted, hard
and anaemic; no hypertrophy : in fact the left ventricular wall seemed
thinner than it should be, and its muscular tissue was brown. Aortic
valves slightly atheromatous and thickened.

Kidneys, both of normal size ; capsules not adherent ; slight increase of
connective tissue in cortex.

Spleen, not abnormal ; liver slightly large, somewhat fatty.

Aorta Immediately upon leaving the valves the arch was greatly

dilated in circumference and length throughout. Its lining membrane
had numerous elevations and depressions, indurations and scars, ulcers of
recent endarteritis and cicatrices, so that there was scarcely any normal
appearance. The openings of the innominate, left carotid, and subclavian
and of the descending aorta were enlarged and atheromatous. The de-
scending aorta was normal, except at its commencement. There was a
branch given off just below the innominate artery, which probably supplied
collateral circulation to the upper extremity. The branches were all
given off near the descending aorta. The dilatation was more extensive
between the aortic valves and the innominate than elsewhere.

The subclavian artery branched off just above the opening of the de-
scending aorta, and for eight centimeters it was irregularly dilated and
atheromatous ; it had two or three very small branches and blind pouches,
and emptied by a constricted ring into the subclavian aneurism, which
was a pear-shaped tumour about thirteen centimeters long and nine wide
at its base, extending, when distended, from the inferior maxilla to the
second rib ; lying upon it and the first rib, which was included in its cav-
ity ; and in close apposition with the carotid artery and side of the neck.
Behind, it pressed upon the cervical plexus ; externally, upon the scapula
and clavicle ; and anteriorly upon the clavicle, which was also included in
the aneurism for a distance of four centimeters. Both the first rib and
clavicle were eroded. The sac itself was thin in places, but strengthened
by laminated blood-clots. The six punctures made by the galvanic nee-
dles were readily seen, and one was in the centre of a black infiltration,
one centimeter square. There did not seem to be any connection between

Reported in the New York Medieal Journal, December, 1880.

452 Chambers, Galvano-Puncture for the Cure of Aneurism. [Oct.

the blood-clots and the punctures. There were a number of dark clots
adhering to the sides of the aneurism, which could be washed off by a
gentle stream of water. The fatal rupture did not start from a puncture.
A few small arterial twigs were seen, and the axillary artery was only
about the size of the lead of a lead pencil. There were no vestiges of the
first needling operation.

This case is interesting for a number of reasons : First, on account of
the rarity of subclavian aneurism on the left side ; and on account of the
long duration of the disease in its advanced condition ; the patient carried
a pulsating tumour upon the side of the neck for two years and a half, and a
fortnight before death it was as large as a child's head. Three hemorrhages
through openings in the sac occurred during the week before the fatal rup-
ture. Were the strange sequences due to the galvanic current, to the ether-
ization, to blood-poisoning, or to embolism and thrombosis ? There is no
doubt a large quantity of foreign matter was thrown into the circulation
by the decomposing action of the electric current upon the steel needles
and the blood. A clot formed at the positive pole was broken up when
the poles were alternated. There were no casts in the urine, and but a
faint trace of albumen at any time.

The autopsy revealed a second aneurism of the arch with extensive
ulcerative endarteritis of the same ; it also confirmed the diagnosis that
the iliac abscess was confined to the abdominal wall, and showed that,
notwithstanding the immense obstruction to the circulation by the two
aneurisms, the heart was not hypertrophied nor was there insufficiency of
the valves.

Galvano-puncture, for the cure of intra- or extra-thoracic aneurisms
lias scarcely had a fair trial in this country, while in Europe it has had
careful study. The first cure reported was that of Petrequin, in 1845, of
a temporal aneurism. Then followed a number of failures, and the Italian
Commission formed at this time was very sceptical. In 1846, Ciniselli
tried it for the cure of aneurisms of the aorta. England, Germany, and
France have had many experiments, and especially valuable have been
the results obtained by Dujardin-Beaumetz and Dr. Laurent Eobin.

Eobin says: 1. It is scientific and rational, and yields practically good
results. 2. It is the best therapeutical agent employed thus far, for it de-
termines in an aneurismal sac the formation of a clot susceptible of organ-
ization. 3. The positive pole alone should be introduced into the tumour
to obtain a firm and resistent clot. 4. This mode of treatment, when
employed with all the precautions pointed out in his work,1 is devoid of all
danger of embolism, hemorrhage, suppuration, gangrene, or of any other
unpleasant accident. It invariably procures relief even in desperate cases.

An old idea was that coagulation was due to inflammation of the sac
surrounding the punctures ; another was that the electric current itself .

1 De l'eleetro-poiicture dans la cure des anevrismes intrathoraciques, 1880.

1883.] C h ambers , Galvano-Puncture for the Cure of Aneurism. 453

caused clotting (Dr. Smee1 passed oxygen and hydrogen through an
albuminous fluid, and obtained a substance resembling fibrin). Robin
is certain " that coagulation is due to the chloride of iron and acid for-
mation of the positive pole, while it is generally agreed that the gelatinous
froth of the negative pole does not tend to organization." He says
further, " the operation is painful, but this is relieved by etherization." 1^
I have the opportunity again, the operation shall be done without ether,
for it is not necessarily a very painful operation. The gas formed in
the aneurism is never sufficient to embarrass the patient. The needle
punctures may be so small that there need be no fear of hemorrhage, espe-
cially if pressure may be applied.

" The current should not be less," says Robin, " than about twenty-one
cells of a GaifFe, Bunsen, or Stbhrer battery ; it should gradually be in-
creased from zero to the greatest intensity, and vice versa ; and it should
be continued about five minutes upon one needle, then upon another,
inserted a short distance off, and so on upon several needles, it should not
be alternated. When the two poles upon two needles are introduced the
action is more energetic, and the clot is formed more rapidly, but is imper-
fect and soft. No clot is formed by the negative needle, but that of the
positive is solid, resistent, and adherent." It seems probable that in
the case just cited the induration within the tumour was changed, when
the currrent was alternated, from a firm consistency to a frothy, gelatinous,
and easily removable matter. Perhaps so much foreign substance thrown
suddenly into the circulation was the primary cause of all the peculiar
phenomena of central disturbance following the second seance.

Robin thinks the clot is due solely to chemical changes, and suggests
always using iron or steel needles, rather than platinum, zinc, or silver.
The clot, he says, is a coagulation of albumen, solidification of fibrin, and
an exudation of plastic lymph.

With regard to the battery, it is necessary that it consist of about twenty-
one small elements, as these produce the least amount of thermic action,
and the greatest intensity of electro-chemically decomposing and destroy-
ing power. The battery of large surface elements is useful as a galvano-
cautery ; the smaller in coagulating or dissolving, according as the posi-
tive or negative pole is used.

An extensive bibliography of the subject may be found in Robin's
work, and the statistics of the work are easily summarized. In a table
there would be found a great many cases under the heading of ameliora-
tion referring to lessening of pulsation, arrest of development of the
tumour, relief of pain, partial or complete, and alleviation of the dyspnoea.
In most cases there would be only one seance, in others even a dozen or more.

Ligation had 33.1 per cent, of death, and galvanism only 12.9 per cent.,
including the bad success of Ciniselli (Norris's table of ligatures).

1 Royal Soc. Trans. 1863.

454 Meaks, Closure of the Jaws. [Oct.

Hutchinson, in 1856, compared it with compression, and found 25 per
cent, success, and 29 per cent, failure in compression ; while galvanism
counted 24 per cent, success, and 30 per cent, failure. But if the positive
pole alone be introduced as before mentioned, the statistics shall be wonder-
ful in cures,

Article IX.

Closure of the Jaws and its Treatment, with the report of a case
in which complete occlusion followed a gunshot wound of the
Left Superior Maxilla, received at two and a half years of age,
and which wtas relieved eighteen years subsequently by opera-
tion according to a new method. 1 by j. e wing mears, m.d., prof.
of Anatomy and Clinical Surgery in the Fenna. College of Dental Surgery,
Demonstrator of Surgery in Jefferson Medical College, etc.

Closure of the jaws exists, as is well-known, under two forms — the
spasmodic or temporary, and the chronic or permanent. The former
occurs usually in connection with some condition which produces irrita-
tion in the motor filaments of the third division of the fifth nerve, causing
spasmodic contraction, notably of the masseter and internal pterygoid
muscles. Among the causes may be enumerated delayed or difficult
eruption of the third molar or wisdom teeth of the lower jaw, the develop-
ment of tumours from the external surface of the ramus and body of the
lower jaw, alveolar abscess in connection with the posterior teeth, necro-
sis, suppurative tonsillitis, and finally I have observed it to follow opera-
tions upon the lower jaw when performed in the molar region.

For the relief of these conditions the treatment consists in the removal
of the causes. When dependent upon the impeded eruption of the wisdom
tooth, the mouth should be opened by levers under the influence of an
anaesthetic agent, and the second molar tooth should be extracted so as to
afford space for the third molar, or, if it is found to be an imperfectly devel-
oped tooth, as sometimes happens, the offending organ should be removed.
For purposes of mastication, the third is regarded as of less value than
the second, and it would seem, therefore, to be better practice to remove
it in all cases. Where tumours, necrosis, and areolar abscesses exist as
causes, the treatment is obvious. After operations in the molar region of
the lower jaw, antispasmodic remedies should be administered and water,
as hot as it can be borne, should be held in the mouth in contact with the
parts so as to allay irritation.

In permanent closure of the jaws we have quite different conditions to

1 Kead at the meeting of the American Surgical Association, held in Cincinnati,
Ohio, June 1, 1S83.

1883.]

Meaes, Closure of the Jaws.

455

deal with. The contraction is not due, in this form, to the perverted
function of pre-existing structures, but to the formation of adventitious
tissues, which firmly and permanently lock the jaws and in some forms
defy successful removal. Although not a very unusual occurrence, it
would appear, from an examination of surgical text books, that the de-
scription and treatment of this truly distressing condition have not, until
a recent period, claimed the attention their importance deserves.

In vol. iii. of the third American edition of Velpeau's Surgery, edited
by Dr. Valentine Mott, of New York, the latter, under the caption of
Concluding Remarks, records sixteen cases which came under his care
from 1812 to 1843, and in which he operated with great success, accom-
plishing perfect cures in all instances save one. He enumerated three
causes upon which "immobility of the lower jaw" depended. The first and
most frequent cause was the formation of unyielding cicatrices, resem-
bling, as it were, adventitious ligaments. A preternatural rigidity or
dynamic contraction of the muscles was stated as the second, and the for-
mation of an osseous plate of bone connecting the upper and lower jaws
was given as the third cause. His process of surgical treatment consisted
in the use of an instrument constructed upon the screw and lever princi-
ple with which the jaws were forcibly separated. The instrument employed
was devised by Scultetus, and depicted in his Armamentarium Chirurgi-
cum. In one case (in 1831) all efforts to separate the jaws were ineffectual,
and he regretted myotomy was not known at the time the operation was
performed, for he was persuaded that subcutaneous division of the masseter
muscle would have liberated the jaws, and resulted in rendering complete
his list of perfect cures. With the expression of high respect for the opin-
ions and statements of this distinguished surgeon, I cannot think that he
was afforded the opportunity of examining, at the expiration of a sufficient
period of time, the results of his method of operation in the cases recorded.

In the Jacksonian Prize Essay of 1867, Mr. Christopher Heath, of
London, recorded cases in which he had performed operations for relief of
permanent closure of the jaws, and in a chapter devoted to the subject col-
lated the work of others up to that date. According to Mr. Heath's
statements, English text books on surgery were remarkably barren of any
information upon the subject. He alludes to a reference of Mr. Cooper,
in his Surgical Dictionary, to a case treated by Dr. Valentine Mott, in
1831, in which an operation was performed for closure of an opening in
the cheek caused by sloughing and accompanied by closure of the jaws.
In the edition of Cooper's Dictionary, issued in 1861, closure of the jaws
is described as occurring after " sloughing of the cheeks and gums from
profuse salivation, the cicatricial bands being so rigid as scarcely to allow
of the separation of the teeth, but they became more pliant in time." The
latter part of this statement, Mr. Heath very justly says, is not borne out
by general experience. Due credit is given to our distinguished President,

456

Meaes, Closure of the Jaws.

[Oct.

Prof. S. D. Gross, for giving " by far the most complete account of the
affection in his large work on Surgery."

Prof. Gross, in the first edition of his Surgery, states, as the most com-
mon cause, according to his observation, " profuse ptyalism followed by
gangrene of the cheeks, lips, and jaw, and the formation of firm, dense,
unyielding inodular tissue, by which the lower jaw is closely and tightly
pressed against the upper. In the worst cases there is always extensive
perforation of the cheeks permitting a constant escape of the saliva and
inducing the most disgusting disfigurement. A second cause is given as
anchylosis of the temporo-maxillary joints, consequent upon injury or
arthritic inflammation. The formation of an osseous bridge, uniting the
jaws or extending from the lower jaw to the temporal bone, is assigned as
the third cause. The effect of the closure is stated to be a serious inter-
ference with mastication and articulation, and if it occur early in life it is
often followed by a stunted development of the jaw.

With regard to treatment, Prof. Gross states that anchylosis of the tem-
poro-maxillary articulation may be relieved by forcibly depressing the
lower jaw with wedges or levers, an anaesthetic agent having been admin-
istered. In order to prevent re-formation of the adhesions, the lever is to
be used daily for many months or years. When the immobility depends
upon the presence of inodular tissue, the proper remedy is excision of the
offending substance — an operation which is both tedious, painful, and bloody,
and unfortunately not often followed by any but the most transient relief
owing to the tendency in the parts to reproduce the adhesions, however
carefully and thoroughly they may have been removed. After the exci-
sion is effected, the ] atient must make constant use of the wedge, wearing
it for months and years so as to counteract the tendency to reclosure. In
a large experience, Prof. Gross found that but few patients were perma-
nently relieved by operations of this kind. Where immobility of the jaw
is caused by the formation of an osseous bridge it may be remedied by
the removal of the adventitious substance by means of the saw and pliers.
Sometimes, however, such a procedure is rendered inexpedient on
account of the long duration and excessive firmness of the anchylosis and
the large quantity of the new osseous tissue.

In cases of long standing it is recommended to divide the masseter
muscle subcutaneously and with great care, lest important vessels be di-
vided. Plastic operations maybe performed to close the gap in the cheek
which may follow salivation.

I have made these liberal quotations from Prof. Gross's work in order
to show how little confidence was reposed in the methods of operation then
in vogue in this country at least, and how unsatisfactory the results were
which followed their employment.

In 1855, Dr. Friedrich Esmarch, Professor of Surgery in the University
of Kiel, read an essay at the Congress at Gottingen on the " Treatment

1883.]

Mears, Closure of the Jaws.

457

of Closure of the Jaws from Cicatriees."1 In this essay he gave an elabo-
rate description of the anatomical relations and histological characters of
the mucous membrane of the cavity of the mouth, as well as of the path-
ological conditions which occur in cicatricial formations in this membrane.
He described the outer space, or buccal cavity as it is termed, between
the alveoli and teeth and cheek and lips as an elastic dilatable sac, and
showed that as soon as this sac shrinks together, loses its elasticity, or is
replaced by a rigid substance, the mobility of the jaw must either be im-
paired or entirely cease. After ulceration or sloughing of the mucous
membrane, cicatricial contraction ensues, which the depressors of the jaw
cannot overcome. If the cicatricial tissue is entirely excised, re-formation
of a cicatrix, possessed, if anything, of greater powers of contraction,
takes place. Mechanical appliances, it is true, such as the metal shields
of Mr. Clendon, of London, dentist, may retard and limit, to a certain
extent, this formation, but it requires their constant use for long periods
of time, and under very painful and trying conditions to the patient. In
order to supply the place of the destroyed mucous membrane, Dieffenbach
suggested, after division and separation of the cicatrix from the bones,
the covering of the raw surfaces with sound mucous membrane trans-
planted from an adjacent part. In the most favourable cases this is almost
impossible, owing to an absence of sufficient healthy mucous membrane
near by. Jaesche, in 1858, recommended the use of a flap of skin instead
of mucous membrane, which may be also difficult to obtain from a favour-
able point. Esmarch, however, would not hesitate to take a flap of skin
from so remote a part as the arm. In view, therefore, of the pathological
conditions which exist in these cases, and of the great difficulties presented
in overcoming them, as well as the failures which followed efforts made,
Esmarch recommended the formation of an artificial joint in front of the
contraction, in order to give the other half of the jaw some, although a
limited, motion. This joint was to be formed by the excision of a seg-
ment of bone of such size as to prevent union of the divided ends, and
the operation was performed by an external incision along the base of the
jaw.

Although this operation was suggested by Prof. Esmarch in 1855, the
method was not employed until 1858, and then by Dr. Wilms, of Berlin.

In 1857, shortly after the suggestion of Esmarch had been made, Prof.
Rizzoli, of Bologna, operated for permanent contraction of the jaws by a
simple division of the lower jaw in front of the cicatrix, using for that
purpose powerful forceps applied within the mouth. In order to prevent
union he inserted a piece of gutta percha between the cut surfaces of bone,
which procedure, it is stated, was accomplished successfully. Satisfactory
results have been achieved by English and Continental surgeons by the

1 Die Behandlung der narbigen Kieferklemme durch Bildung eines kiinstlichen
Gelenkes um Unterkieferkiel, 1860.

458

Meirs, Closure of the Jaws.

[Oct.

employment of both of these methods. Many years before, Dieffenbach
had endeavoured to relieve the closure of the jaws by the division of the
ramus of the jaw, and in this manner obtain the formation of an artificial
joint. This method of operation was not followed by complete success.

In cases where closure results from anchylosis of the temporo-maxillary
articulation, Mr. Heath recommended either division of the bone or re-
section of the joint, giving preference to the former on account of the ease
with which it could be performed from within the mouth " by dissecting
up the mucous membrane and masseter muscle so as to introduce a narrow
saw or strong bone-forceps and dividing the ramus as high up as convenient,
and thus establishing a false joint as originally proposed by Dieffenbach
for cicatricial contractions.

He also quotes from Sedillot the case of true anchylosis in which M.
Grube, in I860, divided the ramus of the jaw from within the mouth with
a straight chisel, and in this way formed a, false joint. The masseter
muscle was subsequently divided subcutaneously, and the cure was per-
manent.

In the last edition of his work on Surgery, Prof. Gross refers to the
two methods suggested by Mr. Heath, neither of which he characterizes
as very promising nor easy of execution. He reports a case of complete
synostosis of the lower jaw on the left side, the result of rheumatism, in
a girl seven years of age in whom, in 1874, he exsected the condyle along
with a portion of the neck of the bone, and succeeded in establishing
excellent motion. The parts were exposed by a curvilinear incision in
front of the ear with hardly any loss of blood, and the condyle was prized
out of its socket by means of an elevator which combined the principles
of a lever and a knife.

Under the date of Dec. 6, 1845, Dr. John M. Carnochan, of New
York, in a communication addressed to Dr. Townsend, translator of Vel-
peau's Surgery, called attention to the fact that he was the first to put into
practice the division of the masseter muscle, and the first to propose
simultaneous division of the masseter and temporal muscles of one or both
sides, and the formation of an artificial joint on the inferior maxillary,
either by simple division of the bone or by exsection of a portion of it as
a remedy for immobility of the jaw. In this communication he reports
at length a case upon which he operated in 1840. After dividing the
adhesions and applying the screw lever, he failed to separate the jaws ; he
then divided the masseter muscle subcutaneously with a narrow tenotome,
and again applied the lever. Again the efforts were without avail, and
before resorting to division of the temporal muscle, as was his intention,
he reapplied the lever, and under the force employed the jaw was frac-
tured in its body. The patient could now open the mouth to the extent
of an inch and a half. The result following this accident, and the suc-
cessful attempt of Dr. John Rhea Barton, of Philadelphia, to form an

1883.]

Mears, Closure of the Jaws.

459

artificial joint in the femur, suggested the application of this principle to
the lower jaw. With the intention of putting this plan into execution at
a future day, the union of the fractured bone was permitted to take place,
and the jaw became again immovable, with a slightly increased space
between the teeth. So far as I am able to ascertain, the operation sug-
gested was never performed. The inference he drew from the results in
the case was that mere fracture or section of the inferior maxilla, even
accompanied by repeated and free motion, would be insufficient to produce
an artificial joint, and that to fulfil this indication the entire exsection of
a portion of that bone (towards the angle or at some other locality which
the nature of the individual case might suggest) would be necessary. It
will be seen from this statement of Dr. Carnoehan that the operations
described as that of Esmarch and of Rizzoli were, in fact, suggested by
him some fifteen years previous to the presentation of the essay of Es-
march at the Congress at Gottingen.

A resume of the methods of operation which have been suggested for
the relief and cure of permanent closure of the jaws shows that they have
been as follows : —

1st. Excision, more or less complete of the cicatricial bands or osseous
formations, and the subsequent employment, for a long period of time, of
wedges and levers to retain the separation of the jaws. Transplantation
of mucous membrane to cover the surface of the wound as suggested by
Dieffenbach, or transplantation of skin as practised by Jaesehe.

2d. Division of the cicatricial tissues, and the adaptation of metal
shields, not only to prevent re-contraction, but to re-establish the sulcus
of mucous membrane at the base of the alveolus.

3d. Dieffenbach's method of simple division of the ramus of the jaw —
and a formation of a false joint behind the point of contraction.

4th. The formation of a false joint as originally suggested by Carnoehan.
Esmareh^s suggestion that it be formed in front of the contraction, and
that a segment of bone be removed for this purpose — by external incision.

5th. The formation of a false joint in front of the contraction by simple
division of the bone, made by forceps applied within the mouth — Rizzoli's
method. In closure due to anchylosis of the temporo-maxillary articula-
tion, the methods practised are: —

1st. Division of the ramus of the jaw from within the mouth, either by
saw., forceps, or chisel, and the formation of a false joint.

2d. Exsection of the condyle with a portion of the neck, the incision
being external.

A patient having presented herself to me for relief from permanent clo-
sure of jaws of long standing, due to cicatricial contraction, I had occasion
to study the various methods of operation which had been proposed for
this form, and became impressed, as the result of this investigation, with
the fact that, objections more or less valid, could be urged against each,

460 Mears, Closure of the Jaws. [Oct.

and that it was possible to carry into execution successfully a method with
the hope of securing better results. Moreover, in two cases I had failed
by the plan of excision, and the use of levers to accomplish satisfactory
results, and I had witnessed similar failures in others. The objections in
cases of cicatricial contraction against the methods of operation above enu-
merated may be stated as follows : —

1st. Excision — The re-formation of the cicatrix and the great pain to
which the patient is subjected in the use of wedges, levers, and screws —
the difficulties of securing flaps of mucous membrane and skin from ad ja-
cent parts and their successful transplantation. The almost universal
failures.

2d. Division and Use of Shields The pain and inconvenience experi-
enced by the patient in the use of the shields, and difficulty of obtaining
the full cooperation of the patient in carrying out the necessary manipula-
tions within the mouth.

?>d. Division of the Ramus behind the Contraction. — Dieffenbach's
Method — The difficulty of obtaining a permanent false joint after simple
section of the bone, and without division also of the overlying masseter
muscle.

4th. Carnochan's Method as practised by Esmarch. — The loss of one-
half of the jaw for the purposes of mastication, where excision is made in
front of the contraction. Its inapplicability when both sides are affected,
and the deformity which results.

5th. Carnochan's Method as practised by Rizzoli The difficulty in

accomplishing the formation of a false-joint by simple division of the
bone — the tendency to reunion being much greater than when a segment
is removed.

Considering these objections I decided to operate upon my patient in
the following manner : By division of the ramus of the jaw, about its
middle, exsection of the condyle and division of the insertion of the
temporal muscle, thus releasing the coronoid process and effecting its
removal with the condyle — division of the masseter muscle at its points of
origin — non-interference with the cicatricial band. By this plan I hoped
to secure sufficient space for free movement of the remaining portion of
the ramus, and I proposed to utilize the cicatricial band as a quasi liga-
ment, and obtain movement of the bone between this band and the inter-
nal pterygoid muscle. By division of the masseter at its point of origin,
I proposed to relieve the tension of this muscle and more effectually pre-
vent union of the divided fibres.

'Case The patient consulted me in January of this year (1883),

and gave the following history of her case : She is now twenty years of
age. Eighteen years ago, when two years and a half old, and then resid-
ing on the banks of the Brazos River in Texas, she sustained a gunshot
wound of the left superior maxilla, the charge, medium sized bird shot,
entering just below the inferior margin of the orbit.

1883.]

Mears, Closure of the Jaws.

461

At the time of the receipt of the injury she was engaged in play on the
porch of her dwelling, and the gun was discharged by a lad thirteen years of
age, whose height compelled him to hold the weapon at an angle in taking
direct aim at her head. This was done in play, the gun being presumed
to be unloaded. The father, who was soon at her side, made efforts to
check the hemorrhage which ensued, and sent immediately for the nearest
physician, living some thirty-two miles distant. Late in the evening he
arrived, "tired and cross," and declined to do anything, as he did not like
to cause unnecessary pain, and as the child was sure to die. After a night's
rest he returned home.

On examination it was found that the charge had entered just below
the left orbit, comminuting the upper and fracturing the lower jaw as well,
passed through the mouth and emerged below the left ear. The father in
the hope of saving his child's life, continued his efforts to ward off fever
and allay swelling by the administration of simple remedies, and the ap-
plication of lint saturated in arnica. At the same time the mouth was
forced open to cleanse it, but so great was the pain caused by the effort,
that it was discontinued. The patient was unable to open the mouth for
the purpose of taking nourishment, and finally all efforts were abandoned to
effect the separation of the jaws, and soon they became firmly locked. At
the expiration of a week following the accident, another physician was
summoned, who removed some wadding, shot, and pieces of bone, and
gave a very unfavourable prognosis as to the recovery of the child.

At the time of the accident the globe of the eye did not appear to be
seriously injured, but the inflammation which attacked the parts and the
cicatricial contraction which ensued in the closure of the wound, destroyed
vision, and drew down the ball to such extent as to expose but a line of
the iris, and produced a marked condition of ectropion. Soon the patient
became accustomed to eat only soft food, which she learned to force be-
tween the teeth. The pressure exerted upon the teeth caused them to
break, and the posterior teeth, which could not be erupted, became carious
and gave pain.

A careful examination of the parts involved showed firm and complete
occlusion of the jaws, absence of the two central and right lateral incisor
teeth of the upper jaw, which had been worn away by the pressure made
in rubbing pieces of food over them. Slight lateral movement could be
obtained, showing absence of temporo-maxillary anchylosis. On passing
the finger into the buccal cavity of the left side, a dense, rigid, cicatricial
band could be felt extending from the molar region of the upper, to the
molar region of the lower jaw. Eight to ten of the anterior teeth of the
upper and lower jaws had fully erupted ; the remaining were imbedded in
the alveoli of the jaws, the edges of the crowns being seen in some in-
stances. Just below the border of the orbit, on the left side, occupying
the position of the upper portion of the canine fossa, there was a deep
sulcus, lined by integument which had been drawn into it, and with it the
lower eyelid ; complete eversion of the lid having been produced, and
the lower segment of the globe being constantly uncovered. This sulcus
was caused by the entrance of the charge of shot. There was marked
flattening of the entire left side of the face produced by the injury inflicted
upon the structures, and the absence of subsequent full development.
On the left side of the neck, on the upper portion, a few shot could be felt
lying beneath the integument, and one was also felt beneath the mucous
membrane overlying the left side of the lower jaw. Articulation was some-
what impiired.

462

Mears, Closure of the Jaws.

[Oct.

On the 26th of January, 1883, 1 operated upon the patient in the man-
ner above indicated, and with a view of relieving, by the one operation,
the condition of ectropion. To accomplish this, I began the incision to
the nasal side of the sulcus, carried the knife through it, and continued
the incision along the lower border of the zygomatic arch to the tubercle
at its base. I then dissected up the tissues from the bottom of the sulcus,
and also from the anterior portion of the floor of the orbit, in order to
release them completely, and thus replace the lower lid. Owing to the
contraction which had ensued it was found necessary to divide this flap
of tissue transversely, bring it into proper position, and secure the edges
by a hare-lip pin. Continuing the dissection, I divided the fibres of'
the masseter muscle separating the entire origin, and then depressed it
with the superjacent structures, thus very easily and completely expos-
ing the coronoid process, the articulation and outer surface of the ramus
to one-half its extent. With strong bone forceps I divided the ramus,

severed the ligaments of the articulation
with the probe-pointed bistoury, then
twisted out the articular head, and finally
detached the insertion of the temporal
muscle, removing the piece of the ramus
which I exhibit.

Efforts were now made with wedges of
wood to separate the jaws, but without suc-
cess. On passing a probe between the jaws
I found a strong osseous band which firmly
united them; this I divided with the Adams
saw, passing it between the imperfectly
erupted teeth, and sawing from before backward. The wedges were again
used, and the jaws separated to the extent of one inch between the pro-
cesses at the position of the incisor teeth. The divided portions of the
osseous band were then cut away with pliers and knife, and found to con-
sist of a thin plate of bone.

On recovery from ether, the patient found no difficulty in opening the
mouth, although it was accompanied by slight pain. In a few days the
pain disappeared, and the mouth could be readily opened. Within three
weeks after the operation twenty-one roots and partially erupted teeth
were extracted, so as to fit the processes for the adaptation of artificial
dentures. The incision was closed by four interrupted silver sutures,
and dressed with lint saturated with carbolized oil. In order to assist in
the exercise of separating the jaws, I employed daily for two weeks a
mouth gag, which I devised some years since, and which works with a
strong screw. In using it the patient complained of pain on the sound
side, the structures of which had become somewhat rigid owing to long
disuse.

At this time the patient is wearing a set of artificial dentures, which are
retained readily in place, and which serve the purpose of mastication
excellently well. The ectropion is relieved so that the globe is covered
by the eyelids. Articulation is much improved. No tendency to re-
contraction is observed. On the contrary, the patient states that her ability
to open the mouth increases each day, and that she can separate the jaws
to a greater extent than was done at the operation and without pain. Exact
measurement gives the distance between jaws, when separated, as one and
a half inches at the position of the incisor teeth.

1883.]

Atlee, Abscess of the Left Iliac Fossa.

463

Whilst in the present case the incision was made so as to relieve the
ectropion as well as to uncover the joint and ramus, I should modify it but
slightly in other instances, as it so completely exposes the parts, and does
not involve either large branches of the facial artery or nerve, thus avoid-
ing excessive hemorrhage or subsequent facial paralysis. It should begin
at the middle of the lower border of the malar bone, and be carried out-
ward in contact with this border and the inferior border of the zygomatic
arch, to a point over the tubercle at its base ; it is desirable to keep near
the border of the zygoma in order to avoid wounding the duct of Steno,
which lies a finger's breadth below.

So far as I am aware, the plan of operation suggested and practised is
novel, in the fact that it includes removal of both coronoid and condyloid
processes with the upper half of the ramus, as well as division of the
masseter, external pterygoid, and temporal muscles, at the point of origin
of the former, and the insertion of the latter. The advantages claimed
over other methods are : —

First. Its application to all forms of permanent closure, that due to tem-
poro-maxillary anchylosis, as well as to cicatricial formations.

Second. The utilization of the entire body of the jaw in opening the
mouth, not only affording in this way greater advantage in mastication
and articulation, but serving to prevent deformity.

Third. The formation of a more perfect artificial joint in the removal
of both processes, thus overcoming the resistance of the more or less fixed
upper segment, when the joint is made either in the body or the ramus
of the bone.

Article X.

Report of a Case of Abscess of the Left Iliac Fossa, with some
Remarks. By Louis W. Atlee, M.D., of Philadelphia.

This case is reported because it shows throughout its whole course the
distinguishing and characteristic features of a phlegmon of the iliac fossa,
together with some very rarely observed occurrences.

Mrs. H.,a3t. thirty-five years, native of Ireland ; has been twelve years
in America. Her father died of an acute disease of the lung (was per-
fectly well, when he took a bad cold and died in two days). Her mother
died of consumption. Mrs. H. is of medium, height, sufficiently well
nourished, and of dark complexion ; has been married two years, and has
previously enjoyed good health. The husband is a robust labouring man.

.On the 10th of March, Mrs. H. gave birth to a well-developed male
child, still-born, after a labour of thirty-six hours. The physician attend-
ing used some force, but no instruments, in dragging the child away. She
did not call it a hard labour.

464

Atlee, Abscess of the Left Iliac Fossa.

[Oct.

The lochia stopped on the second day. Her breasts did not get hard
or show any signs of containing milk ; the nurse rubbed them with cam-
phor and lard.

She did perfectly well for the nine days following delivery, getting up
on the ninth day.

On the evening of the tenth day, after supper, which she had cooked
herself, " a burning pain came into her bench ;" it was in the left side,
deep in the pelvis.

She was not too sick to be about on her feet, the pain at that time
being in no way influenced by position, feeling always the same. In
defecating or urinating, she had not the slightest trouble. There was no
nausea or vomiting ; she could eat, though she had no appetite.

Eighteen days after the pain began, a swelling appeared in the pelvis
on the left side. This swelling reached as high as the crest of the ilium,
but it did not extend near to the median line. After the appearance of
this lump, the pain became frightful ; the slightest motion or jar was
agony; she could neither eat, drink, nor sleep, so that at the end of two
weeks her condition was such that her life was despaired of. Through
all this she was attended by a physician who looked upon the case as one
of rheumatic affection of the hip-joint.

When my father first saw this patient, on the 23d of April, in con-
sultation with the attending physician, her condition was considered to be an
almost hopeless one. At that time, owing to inability to keep any but the
one position upon her back, there was a bed-sore over the region of the sa-
crum as large as the palm of the hand. The thigh was flexed on the pelvis.
To make life at all supportable, a quarter-grain of morphia was being
given every two hours. Owing to the position of the patient, it Avas ex-
ceedingly difficult to examine her sufficiently to establish the diagnosis,
but after considering carefully the history of the case as well as the local
and general symptoms then manifesting themselves, a large tumefaction,
with redness of the skin, in the left gluteal region was believed to be
owing to a collection of pus that had found its way through the ischiatic
notch out of the pelvis. A knife was introduced some three inches before
the matter was reached. The quantity that came out was very great, but
could not be measured, for the patient's position was such that it was im-
possible to collect it. For one week nothing was done but to endeavour to
keep up the strength of the patient, and prevent her from dying. At
that time, the pus seeming not to flow so freely as it had done at first, a
drainage-tube was pushed some eight inches into the orifice.

When I first saw this patient, on the 3d of May, the lump in the left
iliac region was barely perceptible ; pus was being very freely discharged
through the tube, and by pressure on the left gluteal region pus mixed
with air gushed out.

Two weeks after the introduction of the tube, and while the pus was
still flowing freely, she complained of soreness at a spot in the linea alba,
midway between the pubes and umbilicus. A lump began to make its
appearance there, which in two weeks was as large as an orange ; it felt
like an omentocele, and could be all reduced into the abdomen through
a hole in the linea alba that could admit the tips of three fingers. When
on her side, the lump became larger, fuller, and more tense ; when on her
back, it was much smaller. -My father looked at it and said it was a
hernia. Nothing was done to it beyond continual poulticing, when nine
days after its appearance, and while the woman was making some exertion,

1883.]

A t l e e , Abscess of .the Left Iliac Fossa.

465

it burst, giving exit to at least a pint of pus. The opening closed in a
few days, the lump having entirely disappeared.

Seven weeks after the opening had been made in the hip, the fistula there
had entirely healed. During this time she had hectic fever, which only
ceased when the fistula closed. On one occasion (the 10th of May) she
had three congestive chills, during which her lips were blue, and she
shook as patients do only in the most malignant paludal fevers.

So long continued a suppuration brought about such a profound altera-
tion of the functions of digestion and innervation that we almost despaired
of re-establishing them.

During this long ordeal she was given iron, quinine, and morphia, any
food she could eat, and malt liquors.

I saw this patient again on the 25th of June ; she was very much
stronger, being able to leave her bed. She ate well, but still had some
pain, to relieve which a friend advised her to use laudanum (25?^).

On the 26th of June, while lying quietly in bed, she felt a most im-
portunate desire to go to stool, and before she could get up, a great quan-
tity of pus came from the bowel. After this she felt very much relieved.
Notwithstanding the presence of this large quantity of pus in the pelvis,
she had no hectic, a good appetite, and was rapidly gaining strength.
At this time the bedsore was nearly healed, but there was a hole in it that
discharged greatly. This hole seemed to communicate with the interior
of the pelvis, the pus coming from the same abscess that had burst into
the rectum, much less pus coming through at the bedsore after the dis-
charge from the rectum took place.

On the 29th of July they wrote me as follows : " I wish to let you know
that sister Mary is getting better ; her sores are nearly healed up, she is
gaining strength, she takes no medicine at all, but she says that her hip
teels stiff and heavy."

Previous to the publication by Grisolle, in 1839, of his monograph on
" Les tumeurs p hie g monetises des fosses iliaques"1 the various inflamma-
tions liable to give rise to collections of pus in the pelvis were much con-
founded. In this monograph, which is by far the best yet given to us on
inflammations of the cellular tissue or phlegmons in the iliac fossa, he
proves them to be independent of the pelvic serous membrane in their
origin, and generally also in their course. When Bernutz and Goupil pub-
lished their joint observations on pelvi-peritonitis, it was made clear that
peri-uterine peritonitis may and does occur without any disease of the
cellular tissue between the uterus and its serous membrane. The very
existence of this membrane is denied.

The collections of pus that may arise from phlegmon of the iliac fossae
have been anatomically divided into two varieties, subperitoneal and sub-
aponeurotic.

In the first variety, the phlegmon develops between the serous mem-
brane and the fascia iliaca ; in the second, the inflammation is to be found
between the fascia iliaca and the anterior surface of the iliac muscle.

In the subperitoneal variety, the pus is rarely circumscribed, but is

1 Archives Generates, etc., tome iv. p. 34, etc.
No. CLXXII Oct. 1883. 30

466

Atlee, Abscess of the Left Iliac Fossa.

[Oct.

often much extended, the pus burrowing to a greater or less distance.
When on the left side it has been known to burrow along the serous mem-
brane lining the sigmoid flexure of the colon and the upper part of the
rectum, arriving thus in the true pelvis ; or, it may go upwards and reach
the region of the kidney.

In the subaponeurotic variety, the pus occupies generally the internal
iliac fossa ; it is limited in front by the fascia iliaca, behind, by the iliacus
muscle. The pus generally burrows to the front of the thigh in passing
between the fibrous band that is placed outside the sheath of the femoral
vessels and the anterior superior spine of the ilium.

The iliacus muscle is sometimes destroyed, the pus reaching the peri-
osteum of the iliac bone ; the psoas is also implicated, more especially its
internal border. In the same way the quadratus may be destroyed. The
fascia iliaca has entirely disappeared, or contracted very close adhesions
with the peritoneum.

The iliac vessels and nerves bathed in the pus are softened, and if in-
durated spots exist, are compressed.

The migrations of the pus are sometimes very curious. Berard cites a
case of a woman who died of a pelvic abscess following labour ; he found
a vast collection of pus at the posterior and superior part of the left flank ;
it had extended itself outside of the peritoneum, between the iliac fossa
and the intestine, had passed into the right iliac fossa by separating the
peritoneum in the hypogastric region ; it ascended from thence along the
median line to the umbilicus, and there found its way out.

The. exit the pus will make depends greatly upon whether it came from
a phlegmon of the first or second variety.

In the first variety, it is most often seen in the lower part of the belly,
a little above the crural arch.

In the second variety, the pus following and burrowing under the fascia
iliaca will follow the sheath of the psoas and iliacus to arrive at the tro-
chanter minor.

In either variety the abscess may evacuate itself by some of the viscera
contained in the pelvis.

A case is mentioned in which the pus evacuated itself through the uterus.
It was from an abscess of the left iliac fossa following child birth.

The pus following the fibrous sheath of the iliacus and psoas muscles has
invaded the coxo-femoral joint, destroying the fibrous capsule, the head of
the femur coming out of its cavity. This occurrence can be explained
thus: As the pus follows the psoas and iliacus tendons, it may pierce their
common synovial sheath, which communicates with that of the hip-joint.

The pus from these abscesses being found beneath the glutei muscles is
anatomically thus easily explained by Jarjavay {Anatomie Chirargicale,
vol. ii. p. 615, F.). "Beneath the gluteus maximus and its deep fibrous
sheath is a layer of cellular tissue, very loose, and more or less covered

1883.]

Atlee, Abscess of the Left Iliac Fossa.

467

with fat. It communicates, by the great sacro-sciatic notch, with the
subperitoneal cellular tissue and that of the broad ligaments, and below
with the same of the crural region. It results from this that a deep
abscess of the buttock may spread to the upper part of the thigh, and that
a phlegmon following ligature of the gluteal artery can extend into the
pelvis."

In Velpeau and Berard's Manuel d? Anatomie Chirurgicale^ the same
explanation is given.

These abscesses may terminate fatally by bursting into the peritoneal
cavity.

The causes of these iliac phlegmons are very obscure. They are com-
mon after labour, more especially in primiparre. Grisolle could not say
that difficult labour, manual or instrumental interference had any effect
in their production, but he supposes that it is more common in primi-
paras than multipara?, because they generally have longer labour. He
states, particularly, that diffused phlegmon, vast suppurations of the pelvic
cavity frequently follow much handling and unskilfully used forceps.

Yelpeau saw a phlegmon of the left iliac fossa follow inflammation of
that synovial capsule which covers the horizontal ramus of the pubis to
facilitate the sliding of the psoas and iliacus muscles. The same professor
saw a suppurating syphilitic bubo give rise to inflammation in the left
iliac fossa by continuity of tissue.

Grisolle states very decidedly that " nothing would authorize writers
to say as they do, that the annexes of the uterus, and, in particular, the
broad ligaments, were the origin of iliac phlegmons following labour."

These phlegmons have been confounded with pelvi-peritonitis, and in
their commencement with pelvic cellulitis. "When the pus has extended
itself about the pelvis the diagnosis from pelvic cellulitis is impossible as
well as useless. When a pelvi-peritonitis is so mild as to give rise to
symptoms analogous to those of iliac phlegmon, the swelling does not rise
above the brim of the pelvis, nor does it reach to the iliac fossa, and it is
clearly appreciable in one or more of the vaginal culs-de-sac. When dis-
tinguishable in the hypogastrium, which is a very rare occurrence, it is
only at the last when the swelling has increased by successive attacks in
the hypogastrium. Phlegmons are distinguishable from the beginning.

The tumour produced by pelvi-peritonitis does not give the resistance,
elasticity, and hardness that we find in phlegmonous tumours, but gives a
peculiar feeling of softness from the very beginning.

In phlegmon there is little fever or disturbance of the digestive functions
in the beginning, whereas, in pelvi-peritonitis there is vomiting, hiccough,
and high fever, etc.

In pelvi-peritonitis there is no retraction of the thigh.

Collections of stercoraceous matter in the bowel, and masses of intestine,
united by false membranes, have been mistaken for an abscess of the iliac

468

McKay, Observations upon Otorrhoea.

[Oct.

fossa, but such mistakes are hardly possible to a competent practitioner of
medicine.

These brief remarks are appended to the history of this case, because
in no work in the English language, to our knowledge, are phlegmons of
the iliac fossa distinguished as clearly as I believe they should be from
other inflammatory affections in that region.

Article XI.

Clinical Observations upon Otorrhcea (Chronic Purulent Otitis
Media) with Perforations of the Membrana Tympani.1 By Read
J. McKay, M.D., of Wilmington, Delaware, Member of the American Otolo-
gical Society.

Having treated during the past eleven years 230 cases of otorrhoea, or,
more technically, chronic otitis media with purulent discharge, I have
concluded to present for consideration some clinical observations upon
such cases with old perforations of the membrana tympani, and endeavour
to show that they are not the unsatisfactory and irremediable class of aural
diseases which they have long been regarded, and perhaps still are, by
many general practitioners as well as the public generally.

And because of the well-known dangers from caries and necrosis of the
temporal bones, meningitis, cerebral abscess, and purulent infection, which
sooner or later may, and often do ensue, when they are disregarded or
neglected, they should not in the future, as in the past, be permitted by
physicians to pass from under their observation without any or carelessly
directed local and medical treatment.

I shall carefully exclude from consideration at this time all cases of
acute otitis media with recent perforations of the membrana tympani,
which are the usual beginnings of the chronic cases I propose to analyze
and present for consideration, as wrell as their later grave and dangerous
sequelae, of bone, meningeal, cerebral, or septic disease.

One hundred and seventy-six of the two hundred and thirty cases of
otorrhoea (chronic purulent otitis media), about three-fourths of the entire
number, were treated at the Out- door Department of Bellevue Hospital,
New York City, during the five and a half years intervening between
March, 1872, and August, 1877, and sufficiently full notes were not recorded
of their exact condition and progress under treatment, to state definitely
how long they were treated and with wThat results. All of them, I well

1 Read before the Delaware State Medical Society, at its annual meeting held in
Wilmington, Del., June 12, 1883.

1883.]

McKay, Observations upon Otorrhoea.

469

remember, were more or less benefited, many of them I feel sure were
improved, and a small unknown number permanently cured.

Eecent examination of my private case-books shows that of the 54
recorded cases 25 have such full notes as to enable me to state quite defi-
nitely how long they were treated and the results of the treatment.

It was recorded that 24 of the 176 hospital cases had old perforations
of the "drum membranes;" the remaining 152 cases had no recorded
notes as to those common complications.

The 54 private cases recorded had 49 old perforations, and several
others are supposed to have had, but they were neither noted nor counted.

The frequency of the perforations found in the more carefully recorded
cases shows how commonly they occur with chronic purulent otitis media.

In 57 of the cases, perforation of the membrana tympani was found
upon one side only.

In 14 of the cases, perforation existed upon both sides.

3 " 73 cases had 2 perforations in one drum membrane.
1 a a a 3 u u a u a

The usual local complications due to the irritating character of the
purulent discharge, such as the various forms of inflammation of the
external auditory canals, aural polypi, and polypoid granulations upon the
" drum membrane," were not always noted, and will not especially engage
our attention.

I shall present brief histories of the 25 fully recorded cases, so that we
may learn their etiology, duration, condition, and the results of the treat-
ment they received.

Case I. — In the spring of 1873, Mrs. S., aged 30, a resident of New
Jersey, was treated for chronic purulent otitis media with old perforations
of her drum-membranes, which she had had for years. Her hearing was
impaired. She frequently experienced more or less discomfort and pain in
and about her ears. She was carefully treated, and within two months'
time the perforations were healed, her discomfort relieved, and hearing
greatly improved, and these improvements continued more than five years
thereafter, the last report received of her condition.

Case II In February, 1874, Thos. F., aged 32 years, native of Eng-
land, an engineer, reported that at 12 years of age his left ear began to
discharge. Two years afterwards a polypus was removed from it in a
London Hospital, and for two years thereafter he had very little discharge.
Then it gradually became more and more profuse from year to year. His
hearing became so impaired he had to change his work from a boat to the
care of a stationary engine. For the past five or six years he could not
hear his watch when pressed against his left ear. With his right ear he
could only hear his watch fifteen inches, and it had been discharging five
or six months.

A large polypus wras found filling the left meatus. It was removed by
Wilde's snare, and its remaining adhering pedicle was removed by local
caustic applications. Perforations were found in both drum-membranes.
After five-and-a-half months' treatment, each ear could hear his watch
three feet. The discharge had ceased some time previously, and the per-

470

McKay, Observations upon Otorrhcca.

[Oct.

forations had healed. In September, 1875, he reported his hearing re-
mained very good, and that he had no discharge from his ears.

Case III. — October 2, 1878, J. W. L., a schoolboy, aged 18, stated
his left ear had discharged more or less since he had the measles when four
years of age. With it he could hear a watch pressed against the ear, and
the loud voice. After cleansing the left ear by syringing with warm
water and drying it with absorbent cotton, several extensive and old per-
forations and slight granulations of the drum membrane were found.
About three months previously lie got water in his right ear whilst sea-
bathing, causing some deafness and tinnitus. It could hear the watch ten
to eleven inches. No purulent discharge was found in it but a recently
formed perforation of the " drum membrane," which healed in four days'
treatment and gave no further trouble. Within four months the perforations
and granulations of the left ear healed, and remained so several years
after, the last report from him. His hearing, which had been promptly
improved, had continued very satisfactory, and had caused him little or
no annoyance.

Case IV April 5, 1879, B. H., a boy aged 7 years, was first ex-
amined. His mother stated that his right ear began to discharge when
he was six months old, and had done so from time to time since. That
it was always more profuse when he had a cold, from which he was rarely
free. He had naso-pharyngeal catarrh verging upon ozaena. At night he
has been suffering with earache of his left ear, due to subacute aural
catarrh. From his right ear there is a profuse purulent discharge. After
cleansing it a large perforation of the drum-membrane at and below its
centre, one-third of the size of the membrane, was found. His general
health was greatly impaired, and received prompt attention as well as his
ears. The left ear promptly improved, and the right rather slowly but
satisfactorily. The discharge ceased in a few weeks, and the hole in the
drum-membrane diminished more than one-half of its size. He was not
treated so often as desired because of his unusual timidity, and during the
summer he was absent from home, but no discharge was observed. When
he returned in the early autumn the perforation was still smaller, and it sub-
sequently healed. During the winter cold-taking caused it to reopen, but
it again healed after a few weeks' treatment. For more than three years
past he has not experienced any annoyance from his ears.

Case V. — September 20, 1878, Sarah W., a school-girl aged 15 years,
was examined, and aural polypi were found nearly filling her left meatus.
They were destroyed by a few applications of chromic acid and a large
central perforation of the drum-membrane was revealed. It rapidly di-
minished in size under treatment, but never entirely closed whilst under
observation, a period of four months, because of irregularity of visits for
treatment and neglecting daily directions at home to try to remove the
discharge.

Case VI September 26, 1879, C. J., aged 38 years, reported that

when a child he had scarlet fever, which affected both of his ears. They
have discharged more or less ever since — the right ear a purulent, and the
left one a serous, exudation for years past. The hearing of the right ear
was so very much impaired that he relied upon the left one almost entirely,
and with it he did not hear well. He "never had pain in his ears." Ex-
amination manifested that the right drum-membrane had disappeared
except a very narrow rim of its marginal attachment, which was broadest
at its upper edge, and there existed a large central perforation of the left

1883.]

McKay, Observations upon Otorrhoea.

471

membrane. Under treatment the latter diminished to one-half of its size in
a few months, and has remained so. The right drum-membrane began to
re-form by growing from its entire margin, and in June, 1880, a thinly-
prepared and moistened cotton artificial drum-membrane was first intro-
duced to cover the perforation, and it has been worn ever since. It im-
mediately improved his hearing. It requires to be renewed once a week
or oftener, which he has learned to do for himself. The right drum mem-
brane has almost entirely re-formed, and now only a narrow, central,
vertical-shaped opening exists. The hearing of his right ear has greatly
improved for all kinds of sounds, both with and without the artificial
" drum," and he does not now use it constantly. For a year past he has
worn the same kind of cotton artificial drum membrane in his left ear
also, with considerable benefit to its hearing. The improvement in his
condition gives him great satisfaction and comfort. If he experiences
any irritation in his ears from cold-taking or from wearing the artificial
"drums" too long, which cause a purulent discharge, they are removed,
and the use of finely powdered boracic acid at night promptly checks its
formation. The "drums" are worn the next day.

Case VII October 4, 1879, S. B., a little girl aged four years, was

first examined. She had a profuse and offensive otorrhceal discharge from
her right meatus which had existed nine months. Almost her entire right
drum-membrane was destroyed. Her hearing was impaired. She had
inflammation of the left external auditory canal and chronic aural catarrh
of same ear. She had chronic naso-pharyngeal catarrh. The discharge
was soon checked and the large perforation began to diminish, but it did
not close entirely. Her hearing and general condition were decidedly im-
proved in a few months, and remained so for a year or longer, when she
relapsed from cold-taking. In less than a week she was again' relieved.
During the past winter she had a similar experience. Again, about a
month ago, she relapsed during an attack of measles, and the discbarge
was relieved by one visit and within a week. The perforation is still
unhealed.

Case VIII Frank P., an orphan, between 3 and 4 years of age, an

inmate of the " Home for Friendless Children" of this city, was deaf and
dumb when admitted. Could not learn his early history. My attention
was called to his "running ears," which had existed previous to and since
his admission to the "Home."

October 15, 1879, his ears were cleaned and examined carefully. Three
perforations were found in his right drum-membrane and a large one in
the left, which had destroyed two-thirds of its lower anterior portion.
He did not seem to hear or notice any external noise, but smiled and gave
evidences of perceiving the musical sound of a vibrating tuning-fork placed
upon his forehead, which indicated that his auditory nerves and internal
ears were probably not diseased and did not cause or complicate his deafness.
He did not speak at all. When at play with other children would very
rarely make an indescribable noise. He had chronic naso-pharyngeal
catarrh. After a few weeks' treatment he began to hear and to talk in
monosyllables, and later to yell and to sing, which he now does the same
as his playmates. The perforations of the right membrane healed one at
a time during two years under caustic treatment, but reopened several
times " when he took cold." For the past year and a half, under the boracic
acid treatment, they have remained permanently healed notwithstanding
cold-taking. The large hole of the left drum-membrane has grown gradu-

472

McKay, Observations upon Otorrhoea.

[Oct.

ally smaller under similar treatment. It is now a narrow vertical opening
which promises to close soon, judging from the progress it has made in
healing during the last nine months.

Case IX M. W. B., a young man 18 years old, was referred to me

by Dr. Bush, in June, 1880. He reported that six or seven years previ-
ously he had measles which affected his ears, causing a great deal of pain
for a long time, but none the past three or four years. That he had had
a discharge from his right ear for more than four years, and it had become
very offensive during the past three months. For nine months he had
been greatly annoyed by a dry, painful naso-pharyngeal catarrh. He was
debilitated, and apprehended pulmonary disease. With his right ear he
could hear a watch one inch, with the left ear three and a half inches.
Required to be spoken to in a loud voice to hear distinctly. He had
chronic aural catarrh of his left ear. Small polypi were found in his right
meatus attached to its walls and within the tympanic cavity. They were
removed with Blake's aural snare and the remnants touched with chromic
acid. Two perforations were found in the right drum-membrane. Within
two months his hearing was greatly improved, the polypi removed, and
the perforations healed. His naso-pharyngeal catarrh was also much
benefited. In the fall of 1882, two years after treatment, his mother re-
ported that his ears had remained continuously well, and he had greatly
improved in his general health.

Case X September 25, 1880, R. P. B., a school-boy, aged 13 years,

was brought for examination of his right ear, which was discharging pro-
fusely. When two years of age, he had measles, and his right ear dis-
charged for one-and-a-half year thereafter continuously, and then only at
intervals. Three years ago it returned. One year ago it discharged
blood, and again one week ago. Hearing of both ears was impaired.
The left one less so, and it is due to chronic aural catarrh. The right
drum membrane was found to have two large oval perforations in it, situ-
ated before and behind the long handle of the malleus attachment. The
discharge was considerably checked in a few weeks, and the perforations
began to heal all around their margins, and after six months* treatment
they were only one-half of their former size. His hearing had improved
somewhat. The discharge did not recur for some months, until after taking
cold. In December, 1881, the dry boracic acid treatment promptly
checked the discharge, and the perforations began to diminish again. n
the fall of 1882 his mother was instructed how to introduce the cotton
artificial " drum," to be renewed once a week or oftener. Its use greatly
improved the hearing of his right ear when covering the perforations.
He still continues to wear it with much improvement of his hearing.
The perforations were about one-third of their original size a few months
ago.

Case XI J. E., a tobacconist, aged 46, was first examined March

24, 1881. He stated he had had trouble with his ears since boyhood, and
they were usually worse in March. His hearing was impaired, and he
often had pain in his ears. After removing impacted wax and epithelium
it was found he had inflammation of the external auditory canals, and old
perforations of his drum-membranes. After three weeks' treatment they
healed, and his condition was greatly improved in every way. About
eighteen months afterwards he'had a slight relapse of soreness and deaf-
ness, and was relieved by one visit in which his ears were cleansed
and powdered boracic acid was used.

1883.]

McKay, Observations upon Otorrhoea.

473

Case XII — A. L., a boy, aged 7 years, was first examined July 2,
1881. He had scarlet fever one-and-a-half year previously, since which
time his left ear has discharged more or less. His hearing was some-
what impaired. Granulations were found upon his left drum membrane,
and one perforation of it larger than one-eighth of an inch in diameter.
The former disappeared after a few weeks treatment, and within three
months the perforation healed. His hearing was decidedly improved.
He had a slight relapse of otorrhceal discharge from " cold-taking" in the
fall of 1882, which a few days' use of powdered boracic acid checked, and
soon re-established a healthy condition of his ear.

Case XIII F. J. B., a farmer, aged 30 years, reported, October 3,

1881, that before he was six years old he had scarlet fever, which affected
his ears, causing deafness, pain, and discharge. For several years past
he has experienced periods of getting better and worse, which were very
annoying. He has chronic naso-pharyngeal catarrh, and takes cold often
and easily, which always dulls his hearing. He has chronic aural catarrh
of his right ear, and small aural polypi with perforation of membranum
tympanum of his left ear. He was considerably improved by a few treat-
ments, of several weeks' interval, the polypoid granulations removed, and
the perforations healed within two months. He had slight relapses in the
spring and fall of 1882, which were promptly relieved by one visit each
time. He received directions about local and constitutional treatment to
be employed at his home.

Case XIV J. L., a young woman of 19^ years, reported, October

22, 1881, that she had scarlet fever seven years ago, which affected her
ears. One year ago she became somewhat deaf. The last month it has
grown worse, and she is greatly annoyed by tinnitus aurium. She had
chronic aural catarrh of her left ear, and an old perforation of the right
drum membrane. Her hearing was greatly improved at once, and in a
few weeks the perforation was healed. She remained so months after-
wards, the last heard from her.

Case XV.— Miss S. S., aged 20 years, reported, October 29, 1881, that
ten years previously she had ear trouble with the measles. That the right
ear pained and discharged at irregular intervals for four years afterwards.
She has nasal catarrh, and periods of deafness, lasting a few weeks, usu-
ally whenever she takes cold, which occurs irregularly several times a
year.

Examination revealed chronic aural catarrh of left ear, and otorrhoea of
right, with perforation of its drum membrane. Three visits to the office
to receive treatment greatly benefited her in every way, and in less than
a month, her ears were well, and remained so more than a year afterwards,
I was informed.

Case XYI — December 12, 1881, M. C, an unmarried woman, aged
28 years, reported that she had been deaf 9 or 10 years, and lately she had
had considerable tinnitus. Her hearing was very much impaired. She
has chronic aural catarrh of her right ear, its drum membrane very marked-
ly opaque, thickened, and sunken. Her left ear contained purulent dis-
charge, and a large perforation of its drum membrane was found, only a
narrow rim of its margin remaining. Granulations covered the inner
tympanic wall. She had chronic naso-pharyngeal catarrh and hypertro-
phied tonsils. Her hearing was slightly improved at once. Three weeks'
treatment greatly improved her condition in every way, checked the dis-
charge, healed the granulations, diminished the size of the perforation,

474

McKay, Observations upon Otorrhcca.

[Oct.

and decidedly increased her hearing. About a week ago I was informed
her relief had continued permanent and very satisfactory.

Case XVII. — Miss G. C. H., aged 12 years, reported, July 12, 1882,
that her right ear has been affected more or less since she had scarlet
fever when five years old. The ear discharges and is often painful. She
catches cold often and easily, which usually decreases her hearing. Re-
moved an excess of dry wax from both ears, and found a perforation of
the left drum membrane, and granulations upon the right membrane.
Within five weeks her ears were well, her hearing satisfactorily restored,
and no relapse has been reported.

Case XVIII — G. M. S., a school-boy, aged 14^- years, was first ex-
amined July 13, 1882. His deafness makes it difficult for him to attend
school. His ear trouble began two years ago. His mother thinks it is
due to excessive bathing and diving. He has considerable earache.
Both ears discharge, alternately and together. The left one now doing
so. The right one was found occluded with epithelium and wax. Both
drum membranes were perforated, the hole in the right one much the
larger, and more than half of its membrane had disappeared. His hear-
ing was promptly improved, and the discharge checked in a few days.
Within four weeks the perforations were considerably diminished. The
smaller one of the left ear subsequently closed, the larger one of the right
did not entirely. For eight months past he has not had sufficient dis-
comfort to seek further advice.

Case XIX Miss T., aged 17 years, reported August 29, 1882, that

seven or eight years previously she had scarlet fever, and her ears were
affected. During the last two or three years her left ear has discharged
pus profusely and occasionally blood, and it has pained her more or less.
Her hearing is considerably impaired. Examination detected chronic
aural catarrh of her right ear, and aural polypi nearly filling the left
meatus, which was partially removed with Blake's aural snare. Boracic
acid was packed in the ear and within ten days the polypi had completely
disappeared. Then a perforation of the drum membrane was found,
which healed within two weeks under the same treatment, and remained
so two months longer when she was last examined. Her improved hear-
ing was satisfactorily maintained, and she had no relapse up to two
months ago.

Case XX. — R. H., a school-boy, 17 years of age, reported September
24, 1882, that about four years ago he had scarlet fever which affected
his ears, causing them to discharge, and they have continued to do so more
or less from time to time ever since. He has considerable dulness of
hearing. Hears best with his left ear. The right one rumbles and has
bled twice. Examination detected several large polypi filling the right
meatus. They were removed with Blake's aural snare, and found
attached within the tympanic cavity. Chromic acid was applied to the
undetached roots of the pedicles. A large perforation, which had de-
stroyed the lower two-thirds of drum membrane, was observed. A smaller
perforation of the left drum membrane was found. Boracic acid was
packed in both ears. The discharge soon ceased. He improved rapidly
in hearing, the holes diminished in size, especially the longer one, and he
experienced marked relief within three months. He was treated several
times a week for two months, then once a week about same length of
time, and afterwards once a month a few times. He had two relapses of
otorrhceal discharge from cold-taking, which were relieved by one or two
treatments. He continues comfortable and greatly improved.

1883.]

McKay, Observations upon Otorrhoea.

475

Case XXI J. L. P., a school -boy, aged 18 years, was brought to

my office, Nov. 11, 1882, for examination. He has had chronic naso-
pharyngeal catarrh for some years past, greatly obstructing his nasal
breathing, and his ears have (within the last few years several times a
year) been affected with deafness, occasional earache, and slight dis-
charge. Found subacute aural catarrh of his right ear, and eczema of
external auditory canal of his left ear, with a small perforation of its drum
membrane. His hearing was promptly improved and maintained by suc-
cessive treatments. The discharge was checked within two days, and the
perforation healed within a week. His nasal catarrh slowly but steadily
improved under compressed air, atomized fluid applications, and internal
medication. He has had several slight relapses from cold-taking. His con-
dition has been greatly improved in every way.

Case XXII 0. P. B., a young man of 19 years, reported Decem-
ber 28, 1882; he had had "running ears" when a baby, and occasionally
since. He has earache often. Has been more or less deaf for some
years, which increased last summer after sea-bathing. Examination re-
vealed chronic naso-pharyngeal catarrh, and chronic aural catarrh of both
ears, with slight discharge in the left one and a small perforation of its
drum membrane, which healed in a few days. His condition was some-
what improved in two weeks, which was all the time he could be treated,
and I have been informed it has continued.

Case XXIII E. B., a boy of 13 years, presented himself February

24, 1883. His ears began to run five years previously. First one dis-
charged and then the other, and it always increased when he had a cold,
which occurred frequently. Never has any pain about his ears. His
hearing was very defective, requiring to be spoken to in a loud voice gen-
erally, and it is worse when he has a cold. After cleansing his ears large
central perforations of both drum membranes were detected with polypoid
granulations upon the membranes, and attached also to the deep portions
of the external auditory canals. Powdered boracic acid was packed in
both ears, filling the meati. It was to be used at home as soon as the
discharge was manifest again. Four days later, his second visit, the dis-
charge had ceased and the holes were healing. Politzer's method of infla-
tion greatly improved his hearing. The case progressed favourably and
rapidly. Within two weeks all granulation tissue had disappeared. The
perforations were healed to the size of pin-points at his last visit, seven
weeks from beginning of treatment period. He has not reported since,
which he promised to do if any further trouble was experienced.

Case XXIV Miss B., aged 19 years, reported March 20, 1883, that

her ears discharged for a time in infancy and again ten years ago, when
she had scarlet fever ; also they have continued to do so more or less
ever 'since, either alternately or simultaneously, and they are wTorse when
she catches cold, which she often does. She has considerable tinnitus
and dulness of hearing. Has chronic nasal catarrh, which annoys her
very much and prevents her sleeping well. Examination manifested large
perforations of both drum membranes of unequal size, with granulation
tissue upon them. Packed boracic acid checked all discharge in a few
days, destroyed the granulations, and the holes began to diminish in size.
Her hearing was promptly benefited, and it has become much better. The
smallest perforation closed within four weeks, the larger one has not
closed. Her nasal catarrh has nearly disappeared, and she sleeps better
than she has for years past. In eight weeks she has been greatly benefited
in every way, and it promises to continue.

476

McKay, Observations upon Otorrhoea.

[Oct.

Ca.se XXV — Miss C, aged 16 years, reported March 21, 1883, that
between five and six years of age she had whooping-cough, and shortly
after her ears "gathered and run," which has continued more or less ever
since. They are worse in the winter when she catches cold. They often
pain. Her hearing is considerably impaired. Has chronic nasal catarrh.
Examination detected perforation of both drum membranes with granula-
tions upon membranes. Packed boracic acid in her ears, which checked
the discharge within three days; the granulations began to disappear and
the perforations to diminish in size. Her hearing was quickly somewhat
improved, and it has continued to grow better. She progressed favourably
and rapidly, notwithstanding a slight relapse from cold-taking. In eight
weeks all granulations had disappeared and the perforations were closed.
She was recently under observation for examination.

A short recapitulation of the results and methods of treatment will, I
think, be interesting and striking.

In 17 of the 25 cases fully reported, the perforations of the drum
membranes were healed, viz: Nos. 1, 2, 3, 4, 9, 11, 12, 13, 14, 15, 16,
17, 19, 21, 22, 23, and 25.

In 4 other cases in which perforations existed in both ears, viz : Xos.
8, 18, 20, and 24, they were healed in one ear and were not in the other.

In the remaining 4 cases, viz: Nos. 5, 6, 7, and 10, they were not
healed, but the discharge was checked, the perforations diminished in size,
and their hearing was greatly improved ; in fact, their condition was in
various ways more or less ameliorated and rendered much more comfort-
able.

The first 15 cases were treated by various caustic applications, and they
required usually several months' treatment to relieve or cure them.

The remaining 10 cases were treated with finely powdered boracic acid
packed in their ears, usually filling the meati the first few visits, which
generally checked the purulent discharge in a few days, and only required
several weeks (usually about four) to relieve or cure them.

The latter treatment (known as the dry method), besides its great sav-
ing of time, is painless, and the only objection patients make to its use is,
that it renders them more deaf for a few hours immediately after its in-
troduction. But as it is only for the first few applications (until the dis-
charge is checked), they submit after explanations that it will be merely
a temporary inconvenience.

The 25 cases were selected to be reported because full notes were made
of them from the beginning to the end of their treatment.

The remaining 29 cases of the 54 private cases were omitted because
pressure of business prevented full notes being made of their progress
under treatment, and I feel confident that their average of relief or cure
compares very favourably with those detailed.

1883.] Grossmann, Modified Porro-Coesarean Operation. 477

Article XII.

A Modified Porro-C.esarean Operation : The Pedicle Dropped In.
By Paul Grossmann, M.D., of Omaha, Nebraska.

On Sunday, May 7, 1882, I was called to attend, in her first labour
at term, Mrs. Louise Cuneo, a rachitic dwarf, 23 years of age, and measur-
ing four feet one inch in height. The waters had broken before her
pains began, and at my visit, her pulse was 72, and temperature 98^-°.
I was informed that the patient was one of eight or nine children, born
of sound, healthy German parents, whose four sons were well built, whilst
all their daughters were like this one, rachitic.

I found, upon examination, that the arms of the patient were short/and
presented the usual rachitic appearances. Her right lower extremity was
of the shape of a long S, and the patella looked outward, notwithstanding
which, the leg could be placed at nearly a right angle with the thigh, and
the foot, in standing, rested with its plantar surface upon the floor. The
left leg was not so much deformed, and both tibiae presented the evi-
dences of disease, in the fact that there was a convexity of these bones in
their lower third.

On examination of the pelvis, it was found to be asymmetrical, and con-
tracted in all its diameters, but chiefly antero-posteriorly. The lower con-
jugate, or the conjugata diagonalis, was found to measure about three inches;
deducting | of an inch, would leave the antero-posterior diameter of the
superior strait at 2 J inches. The lumbar vertebrce were found to retreat
very abruptly from the promontory of the sacrum. The coccyx projected
forward in the characteristic hook form often seen in rachitic women. The
os was undilated.

During Monday, the pains were rather strong, and the patient was given
occasional doses of opium. Monday night they became still stronger, and
^ of a grain of morphia was given hypodermically, and two more doses of
J of a grain each by the mouth at 1 and 7 A. M. Tuesday. At this time
there was only sufficient dilatation of the os to admit the tips of two fingers.
During Monday the patient's pulse was about 100. On Tuesday it gradu-
ally increased, till it had reached 144 at 10 P. M. The waters had entirely
drained away «by Tuesday morning.

On Monday and Tuesday the question of forcible delivery had been
presented to the family, and they were informed as to the operations of
craniotomy, Cesarean section, and the Porro operation. They delayed
their decision, but finally consented to the performance of craniotomy, re-
fusing to allow her to be removed to the hospital, or any other more con-
venient place. In order to secure better dilatation of the os, at 4 P. M.
Tuesday, the patient was given ten grains of hydrate of chloral, and three
of quinia, and this dose was repeated every thirty minutes for three doses,
and every hour for three more.

. At 10 P. M., after the long delay, it was seen that the patient's strength
was declining, and it was deemed essential to operate at once. Much
valuable time had been lost in an effort to secure permission for the per-
formance of abdominal section, which was persistently denied ; finally, I
under protest undertook to perform craniotomy. The os was now found
more dilated and easily dilatable with the fingers. The child was still
living and found to be in the first position of the vertex. I applied the

478 Gros smann, Modified Porro-Caesarean Operation. [Oct.

craniotome to the right parietal bone, and found no trouble in perforating
it. As much as possible of the brain substance was removed with the aid
of an elastic catheter, and parts also of the frontal, parietal, and occipital
bones. I then attempted podalic version with the right hand, passed in on
the left side of the pelvis; my hand was passed through the pelvis with
great difficulty, and when forced far enough to engage the upper third of
the forearm in the pelvis, it was compressed so tightly that it was impos-
sible to flex the fingers ; the hand readied the child's right knee, but I
was unable to grasp it, or go further, and the combined pressure of the
narrow pelvis and the uterine contractions were unbearable and required
the instant removal of the arm. After a few moments' rest, I made another
attempt at version with the left hand, passed in on the right side of the
pelvis. On account of the asymmetrical character of the pelvis, this was
found still more difficult, and the hand could not be inserted as far as the
knee. Two more attempts were made with the right hand, and one more
with the left, but it was impossible to grasp the child's knee, or reach its
foot.

The uterine contractions were now so violent that rupture of the uterus
was imminent ; the patient had been profoundly anaesthetized for nearly
five hours ; meanwhile, subjected to craniotomy ; and I felt that it was
useless to prolong the attempt at embryotomy, and, after a brief consulta-
tion with other physicians present, I decided to insist upon abdominal
section as the only possible means of saving the mother, and to perform
the Porro operation, so that, if the patient lived, future impregnation would
be impossible. She had then been in labour sixty-six hours, and her
pulse ran from 140 to 144 per minute.

The family now yielded to my demand, and I made an incision from
two inches above the umbilicus, almost to the symphysis pubis ; the opening
of the abdominal cavity was made without difficulty, or the necessity of
applying a single ligature. The small intestines and the omentum pro-
truded and were replaced.

I made an incision eight inches long in the uterus ; seized the legs of
the child, a good-sized boy, and removed it ; fortunately, the placenta was
attached to the posterior uterine wall. The uterus was then lifted out of
the abdominal cavity, and eight ligatures were applied in the right broad
ligament ; a curved needle armed with a double silk ligature was passed
through segment after segment of the ligament and each one tied as soon
as passed. An incision was then made from the long incision in the
uterus, but at right angles to it, almost to the ligatures across the broad
ligament, and one-half the uterus just above the internal os was separated
by scissors from the part beneath ; six ligatures were similarly inserted in
the left broad ligament ; another right-angle incision was made nearly
to these ligatures, and by means of the scissors the complete removal of
the uterus above the internal os was made.

The uterus, Fallopian tubes, and ovaries were then removed. An ex-
ceedingly small quantity of blood was lost during the operation.

Six sutures were then inserted in the uterine stump, and a perforated
elastic catheter was inserted through the abdominal wound, stump, and
vagina for drainage. The ends of the ligatures were cut off, the stump
returned, to the cavity, and this thoroughly sponged out. The operation
was performed without spray, or other antiseptic preparation.

An examination of the pelvis showed that the antero-posterior diameter
of the superior strait was only two inches, and the pelvis very asymmetrical.

1883.] Van Harlingen, Naphtol in Skin Diseases.

479

The abdominal incision was then closed by ten ligatures, with careful ap-
proximation of the peritoneal surfaces. The wound was dressed with
lint moistened with carbolized oil, and the patient bandaged and removed
to her bed ; she now became conscious and asked for her child. She
was given some stimulant and a hypodermic injection of morphia ; she
conversed a little and fell asleep. Her pulse at the conclusion of the
operation was 128, but as soon as she emerged from the anaesthesia it
began to intermit, losing every tenth beat, for an hour and a half.

At 6 A. M., her pulse was 128, and respiration 28. At 8 A. M., her
pulse and respiration were the same. During the day she was given
nourishment and stimulants which she retained, and was kept under the
influence of morphia. At noon her urine was withdrawn by catheter,
and some tympanites was discovered. More morphia was given at this
hour, and the patient expressed herself as feeling better and hungry. At
noon her pulse was 132, respiration 24, temperature 98^°. At 5 P. M.,
delirium was present, the tympanites more marked, and the pulse was
fluttering ; stimulants were now pushed. At 7.45 P. M. she was pulseless,
and fifteen minutes after this, died — fourteen hours after the operation.

I feel confident that the above operation would have been a successful
one if performed at the very beginning of labour.

Article XIII.

Experiments in the Use of Naphtol for the Treatment of Skin Dis-
eases. By Arthur Van Harlingen, M.D., Professor of Skin Diseases in
the Philadelphia Polyclinic.1

Naphtol was first brought to the notice of the profession by Professor
Kaposi, of Vienna, about two years ago2 as a sort of substitute for tar
and its preparations. The substance used by him is the j3 naphtol of
chemistry, a derivative of coal tar which occurs in commerce as an indis-
tinctly crystalline substance of a dusky mulberry colour, semi-transparent,
and resembling coarse rock salt.3 It has a faint odour, slightly like that
of coal tar, but at the same time aromatic. Its chemical constitution
is said to be represented by the formula C1GH80. It melts at 122° C.
and boils at 290° C. It is soluble in an equal weight of alcohol, very
slightly so in water, but readily in alcohol and water. It is also soluble
in fixed oils and fats. In solution and ointment its odour is scarcely per-
ceptible. In thin strata the preparations of naphtol are colourless ; after
long exposure to the air they become red. They do not stain the skin or
hair, and do not usually discolour linen or other dressings. The solution

1 Read before the American Dermatological Association at its seventh annual meet-
ing, Lake George, August 30, 1883.

2 Wiener Med. Wochenschrift, Nos. 22 and 23, 1881.

3 More recently a reerystallized naphtol, in fine gray pearly scales, has appeared in
the market.

480

Van Haelingen, Naphtol in Skin Diseases.

[Oct.

and ointment of naphtol were at first used by Kaposi in various strengths,
from one quarter to ten per cent., or even higher.

A later communication from Kaposi1 gives the result of further and
more extensive experience with naphtol. He had treated up to that time
about a thousand cases of skin disease, and for the most part with strik-
ingly good results. No untoward effect had been noticed in any case,2
nor indeed any inconvenience further than a certain amount of local irri-
tation even when the naphtol had been employed in a considerable degree
of concentration, and had been applied during a period of several months
and over large areas of integument.

According to Kaposi, even fifteen to twenty per cent, solutions of naph-
tol in oil or ointment fail to irritate the healthy integument when rubbed
in or applied on cloths. On the contrary, such applications simply give an
agreeable softness to the skin. When, however, the skin is inflamed,
even subacutely as in chronic eczema, a single application of a weak, one
per cent, ointment will excite acute inflammation. Kaposi's experience
also shows that weak alcoholic solutions (one half to one per cent.) react
energetically even on healthy integument. After one or two applica-
tions the skin becomes brown and desquamates slightly. On pushing the
application a little further an erythematous inflammation is excited.

Naphtol is absorbed to a considerable extent by the skin and is ex-
creted by the kidneys, giving the urine a cloudy wine-brown colour. A
sort of toleration appears to be established after a time.

The only form of naphtol employed by Kaposi has been that known as
/3 naphtol; he has found the other naphtols irritating in their effects upon
the skin.

My attention having been drawn to naphtol by Kaposi's first article, I
imported a quantity by the kindness of Mr. H. B. Rosengarten, of Phila-
delphia, but was prevented from making use of the remedy until the begin-
ning of last spring, when I employed it at first in the clinic at the Uni-
versity Hospital, and later in my service at the Polyclinic, and in a few
instances in private practice.

Although the comparatively small number of cases in which I have been
able to make use of the remedy would preclude any independent conclu-
sions as to its value, yet I am led to believe that, stated in connection with
the conclusions of Kaposi, my results tend to show that we have in naph-
tol a remedy of considerable virtue in certain skin diseases, and one worthy
of a wrider trial and employment. I shall now give Kaposi's experience in
the various affections in which he has used naphtol, adding the results of
my personal experience by way of commentary.

Of the thousand cases treated by Kaposi, 536, or more than one-half,

1 Wiener Med. TVochenschrift, No. 31, 1882.

2 Other observers have noted cases where hemoglobinuria has ensued on the too
prolonged use of naphtol or its employment over an extensive surface.

1883.]

Van Haelingen, Naphtol in Skin Diseases.

481

were scabies. The formula employed by him in the treatment of these
cases is as follows: R. — Axungiae, 5 viij ; saponis viridis, §iss; naphtolis,
5iv; pulvis cretse alboe, 3ij — M. In hospital practice a single energetic
application of this ointment is made over the affected parts, after which
the patient is thoroughly powdered with starch, and wrapped in a linen
sheet. In private practice, under-garments of linen are placed upon the
patient after powdering the anointed skin, and he can then go about his
ordinary avocations. A single day in hospital is enough for scabies
patients, no eczematous eruption being excited by the naphtol ointment,
and the irritation already existent being greatly allayed. This point, in
connection with the total absence of odour in naphtol ointment, gives it
very greatly the preference, in Kaposi's opinion, over the ordinary oint-
ments employed in the treatment of scabies. The more eczema there is
in connection with the scabies, the more striking is the superiority of the
naphtol treatment.

I have had but little experience in the treatment of scabies, since the
proverbial cleanliness of the lower class of Philadelphians makes them the
very antithesis of the filthy Austrians forming Prof. Kaposi's clientele.
As far as I have had any experience, however, it has been eminently
favourable to the naphtol treatment, and I have no hesitation in saying
that I believe it to be the very best treatment for this affection which has
yet been brought forward. A single case will suffice to show the manner
in which the naphtol was employed.

Case I. — On June 9th last, a young man applied at my service in the
Philadelphia Polyclinic for the treatment of a typical though not severe
attack of scabies of six months' duration. Extreme cleanliness with some
inetfective treatment had prevented the extension of the disease, but well-
marked lesions existed in considerable number, chiefly about the hands,
axillae, penis, abdomen, and buttocks. The patient was ordered: R. —

Naphtol, 9iv; vaselini, §j M. To be well rubbed in every evening.

The patient returned in a week almost entirely cured, and a few more
applications sufficed to remove all traces of an eruption which half a year's
treatment had failed to heal.

Hardy, of Paris,1 whose opportunity for observing scabies is as great
as that of Kaposi himself, is enthusiastic in the praise of naphtol in the
treatment of this disease. He employs a 10 per cent, ointment, made by
dissolving the powdered naphtol in half its weight of ether, mixing with
a portion of the vaseline, heating to between 86° and 104° F., and add-
ing the rest of the vaseline with careful trituration. The homogeneous
ointment thus made is kept from the contact of air. According to Hardy,
this ointment may be used in all stages of scabies, and of the accompany-
ing eruptions. Though slower in its action than sulphur, the itching that
sometimes follows the sulphur treatment is absent after the employment
of naphtol.

1 Guerin, These de Paris.
No. CLXXII — Oct. 1883. 31

482

Van Harlingex, Naphtol in Skin Diseases. [Oct.

Kaposi has treated seventy-one cases of eczema by means of naphtol. In
the squamous stage of the disease, when the affected skin is slightly
hypenemic, or is already becoming paler, naphtol may be used instead of
tar to complete the cure, a \ to 1 per cent, ointment being applied once
or twice a day, in a thin layer. After each application the patch is to be
covered again with powdered starch.

In the squamous stage of eczema a cure is effected more rapidly if ap-
plications of alcoholic solutions of naphtol, J to 1 per cent, strength, are
made daily. This solution is more apt to irritate than the ointment, and
should be carefully watched. When the epidermis takes on a light-brown
colour the cure is complete and the naphtol should be withdrawn. In
chronic squamous eczema ointments of 2 to 3 per cent, strength may be
rubbed in. Naphtol soap may also be used, either rubbed in, or in torpid
cases allowed to remain in contact with the skin.

In impetiginous eczema of the scalp, Kaposi uses, with good results,
oils of naphtol containing one part of naphtol to one hundred parts of oil
of olives, cod-liver oil, or oil of sweet almonds. Intercurrent cleansing
by means of spiritus saponis kalinus, alcohol, naphtol soap, or naphtol
sulphur soap, may be used to prevent the accumulation of crusts, etc.

In other affections of the scalp, as pediculosis, tinea tonsurans or favus,
or where eczema impetiginosum is an accompaniment, Kaposi also em-
ploys this treatment, regarding naphtol as an excellent parasiticide.

My experience with naphtol in the treatment of eczema has led me to
conclusions entirely opposite to those arrived at by Kaposi, as I have
failed in every case where I have used this remedy to obtain any satis-
factory result. A number of cases put upon the use of naphtol ointments
and washes failed to report the results of treatment, which led to the con-
clusion that it must have been anything but satisfactory. This occurred
with all the cases of vesicular eczema.

Case II A child, two years of age, brought to the Polyclinic with an

eruption of vesicular and papular eczema about the genital and sacral
region ; was ordered at first a saturated solution of boracic acid as a wash.
But little change taking place in the appearance of the eruption after two

weeks' treatment, this was changed to the following: R Naphtol, 5j 5

ung. aq. rosas, 5iv — M. This proved decidedly irritating, and after using
it for several weeks the naphtol was stopped, and an ointment of one
drachm bismuth subnitrate to the ounce of cold cream was ordered. In
five days the patient was discharged cured.

Case III A patient suffering with well-marked papular eczema of the

body and limbs of a month's duration was placed upon the use of the

following wash : R Naphtol, Z>ss; alcohol, f§j ; aquas, ad Oj. — M. (1.5

per cent, solution). In a few days the patient returned to the clinic com-
plaining that the wash burned the skin without allaying the itching. An
ointment of naphtol of the strength of half a drachm to the ounce was
then prescribed. This agreed much better with the skin, and allayed the
itching, which was a prominent feature. The patient soon after disap-
peared from view, so that the final result of treatment was not ascertained,

1883.]

Tax Harlingen, Naphtol in Skin Diseases.

483

but enough good effect bad been produced to confirm Kaposi's statement,
that the ointment of naphtol often agrees with the skin, wheti a wash of
even less strength irritates. Here the wash was of about one-half per
cent, strength, while the ointment was of nearly six per cent., but the
former irritated the skin, while the latter did not.

Case IV In another case of papular eczema, affecting the leg, naphtol

was employed in an oily solution : R — Naphtol, ; ol. amygdalae, f§iv. —
M. This solution (about 2 per cent.) failed entirely to relieve the itching,
or to ameliorate the disease.

Case V In the case of a papular eczema, involving the arm and

anterior axillary border, an ointment of naphtol, one drachm to the ounce
(12 per cent.), gave rise to great burning with roughness of the skin.
Lotio nigra, with zinc oxide ointment, subsequently relieved the patient
in a few days.

Case VI. — An ointment of ten grains naphtol to the ounce (2 per cent.),
employed in a case of typical eczema rubrnm of the leg, had little or no
influence upon the disease, although it did not seem to irritate the skin.
A stronger ointment, two drachms to the ounce (25 per cent.), made use
of in another case, gave rise to severe irritation and abrasure of the skin,
without relieving any of the symptoms.

Employed in squamous eczema naphtol seemed to act more favourably,
although further experiment would be desirable to ascertain the proper
strength of the ointment.

Case VII. — A boy, of fifteen, applied at the Polyclinic on July 5, show-
ing a well-marked squamous eczema of the scalp. A solution of half a
drachm of naphtol in an ounce of olive oil (nearly 7 per cent.) removed
the scales very nicely. At the end of a week these were all gone, but the
scalp seemed irritated and about to pustulate. The naphtol was then
stopped, and a mild bismuth subnitrate ointment substituted. In three
days the scalp was about well. I am inclined to think that in this case
a weaker solution of naphtol would have proved more effectual.

Case VIII. — A slight case of palmar eczema in a child ; was directed the
use of naphtol ointment, one drachm to the ounce (12 per cent.) After
using this ointment some time no effect could be perceived, but the disease
was finally, though slowly, removed.

From this series of cases, selected from a considerable number of cases
of eczema treated by naphtol, it is plain that its use was in most instances
unattended by any perceptible benefit.

Kaposi shows himself particularly enthusiastic over the success of his
treatment of prurigo, which, in his hands, has now become a curable dis-
ease. He has treated thirty-three cases with naphtol. Prurigo being
practically an unknown disease in this country, I have had no experience
in its treatment.

In ichthyosis, of which five cases came under Kaposi's care, he was
able to suppress the employment of baths, employing inunctions with a
five per cent, naphtol ointment once or twice a day. Under the influence
of this treatment the skin is said to become rapidly smooth and supple,
and the eczematous complications to disappear gradually. In severe cases

484

Van Harlingen, Naphtol in Skin Diseases.

[Oct.

Kaposi begins with the following: R. Saponis viridis seu ol. morrhuie,
pts. c ; naphtolis, pts. ii, rubbed into the skin, with intercurrent baths, in
which naphtol soap is used, until slight exfoliation of the epidermis is pro-
duced. After this an ointment of live per cent, strength is to be employed.

Prurigo and ichthyosis naturally require persistent care even after the
skin appears to have assumed its normal appearance. One or two baths
a week, in which naphtol or naphtol-sulphur soap is used, followed by
applications of five per cent, ointment, should be employed. In order to
afford protection against absorption, when the treatment has to be carried
on for several months, Kaposi recommends that every three weeks an
emollient ointment be substituted for a while, or the following ointment

may be employed: R Glycerin, amyli, pts. c; acidi borici, pts. v. If

moist or crusted eczema exists, together with the ichthyosis, in any given
case, this condition must first be removed before the ichthyosis or prurigo
can itself be treated.

I have not yet had an opportunity of using naphtol in ichthyosis, but
I think it promises well if we can reason from the analogy of its action
on the epidermis in connection with Kaposi's limited experience.

In psoriasis Kaposi uses a fifteen percent, ointment, the action of which
is, he thinks, less disagreeable than that of chrysarobin or pyrogallic acid.
Pie especially prefers naphtol in psoriasis of the scalp and face, because it
does not discolour the skin or hair, and does not give rise to irritation like
the former remedies.

My experience strongly corroborates Kaposi's statements as to the ad-
vantages to be derived from the use of naphtol in psoriasis, as the follow-
ing notes will show : —

Case IX A man, of thirty-four, presented himself at the Polyclinic

on June 22, with psoriasis of some years' duration, for which various
treatment had been employed with little avail. His scalp was filled with
thick yellow masses of scales, and in places, particularly the forehead
and vertex, was nearly devoid of hair. There were also numerous well-
marked and typical patches scattered over the body. The patient was
ordered inunctions with an ointment containing one drachm of naphtol to
the ounce of lard, to be applied to the patches upon the body, while a
naphtol soap, composed of R. Naphtolis, §ij ; saponis viridis, 5j. M., was
ordered to be used upon the scalp ; some of the lather remaining after
washing to be left in contact with the surface. No internal treatment
was employed.

The result was more striking than I had any reason to expect. Within
four wrecks the scalp was almost entirely well, and the various patches on
the body had in some cases disappeared, leaving a brown stain, while in
others, where the rubbing had not been so thoroughly performed, there was
still a certain amount of infiltration. The patient, who was much pleased
with the result of the treatment, said he had not been so well since the
disease first made its appearance. I should add that the season could not
have had any effect, as the eruption had in previous years been as bad in
summer as in winter.

1883.]

Van Harlingen, Naphtol in Skin Diseases.

485

Case X A second case presented itself in a middle-aged German

woman, who had suffered from the disease for fifteen years, and in whom
the psoriasis presented itself in large well-marked patches pretty well
distributed over body and limbs. She was placed upon four minims of
Fowler's solution, Avhich, however, failed to prevent the outbreak of new
lesions, and seemed to have, but little effect on the older ones. Certain of
these, however, having been rubbed with an ointment of naphtol, of the
strength of one drachm to the ounce, began to fade and diminish with great
rapidity. After about three weeks' treatment, this ointment was changed
to one made according to Hardy's formula by dissolving the naphtol in
ether and then rubbing up with vaseline. This ointment, used in the
strength of one part to ten, or a little weaker than the former, did not
seem to agree so well, and was soon dropped. When last seen this patient's
eruption was nearly well in all places which had been touched by the
naphtol ointment, while some patches which had been neglected were
only slightly improved.

Although the naphtol ointment, as used in some other cases of psoriasis
coming under my care, failed to give the results expected, yet there were
circumstances connected with the eruption, which was in a more acute and
inflammatory condition than in the cases given, which would account for
this want of success.

I think that naphtol will prove a valuable addition to the remedies at
present used in psoriasis. Its efficiency is, I think, nearly or quite that of
pyrogallic acid, with less danger of toxical effect when used on large
surfaces, and without the tendency to stain. Compared with chrysarobin
its action is much less efficient and rapid, but the well-known objectionable
features of treatment by the latter agent lead to the contented use of a
less powerful but less disagreeable application.

In using Kaposi's naphtol treatment of seborrhoea of the scalp, the
masses of sebum are first to be softened with oil of naphtol 1 per cent.,
and then the scalp is to be washed either with spiritus saponis kalinus or
with naphtol soap. Afterwards the alcoholic solution of naphtol (25 to
50 per cent.) is to be kept applied for five to seven days. At the end of
this time a transparent brown pellicle of smooth, uniform, very adherent
epithelium, is found on the pale skin. The usual stimulant applications
may then be made to the scalp, or, if hyperemia persists, the alcoholic
solution of naphtol may be once more applied. The same treatment may
be employed advantageously, according to Kaposi, in premature alopecia
due to seborrhoea in anaemic women or men, as well as in scaly seborrhoea
of the nose and other parts of the face.

• But few cases either of true seborrhoea sicca capitis or of that form of
pityriasis of the scalp which is usually confounded with it, have come
under my notice since I have read Kaposi's latest paper on naphtol.

Case XI. — In one of these cases a young girl presented well-marked
seborrhoea of the scalp ; great benefit Avas derived from the use of the fol-
lowing: R. — Naphtol, 9j ; sulphuris, 3SS ; saponis viridis, 5*v M»

486

Van Haelingen, Naphtol in Skin Diseases.

[Oct.

This was used as a soap with hot water to cleanse the scalp once daily, a
small portion of lather being allowed to dry on the scalp. At a later date
a solution of naphtol in alcohol, twenty grains to the ounce (4 per cent.),
was employed in the same case, also acting favourably.

Case XII — A second case, also in a female, of fairly well-marked
seborrhoea sicca was placed upon an ointment of naphtol in vaseline, one
drachm to the ounce, under the use of which very marked improvement
was noted during the time the patient was under observation.

In acne, acne rosacea, sycosis, and lupus erythematosus, Kaposi has ob-
tained excellent results from the methodical application of naphtol in the
form of naphtol soap, naphtol sulphur soap, and a paste composed of alco-
hol, sulphur, and naphtol. In these cases the foam of the soap is allowed
to remain in contact with the skin over night, and is washed off next
morning, while some other preparation which will permit the patient to
go about his occupations is applied during the daytime. In acne and
sycosis "Wilson's ointment" (ung. zinci ox.) may be used for this pur-
pose, while the same ointment or emplast. hydrarg. may be employed in
lupus erythematosus. Better still, in some cases, the naphtol application
is repeated in the morning until a thin brown epidermic pellicle is formed.
This adheres the more closely the more the effect of the remedy is pro-
duced, that is, the more the tumefaction and hyperemia have diminished.
In lupus erythematosus this amelioration manifests itself by flattening and
disappearance of the edges, which have been sharply cut and deeply in-
filtrated.

The following paste will often take the place of the soap application:

R Naphtol, gr. iv ; sp. sap. kal. gr. c; alcohol, gr. cc ; balsam Peru,

gr. viij ; sulphur precipitate gr. xl. — M.

Having had no experience as yet in the treatment of these affections by
means of naphtol, I cannot, of course, express any opinion regarding the
efficacy of the drug.

In hyperidrosis of the palms, soles, etc., Kaposi has obtained rapid,
often immediate relief by the aid of naphtol applications. In many cases,
however, the secretion of sweat returns after a time, just as it does after
the use of other agents. Kaposi employs the following formula: R. —
Naphtol, gr. xxiv ; alcohol, ; glycerine, gr. 1 — M. This is to be applied
twice daily, and followed by powdered starch alone or containing two per
cent, of naphtol. In hyperidrosis plantarum, cotton impregnated with the
powder may be placed between the toes.

In one case bad results followed the use of naphtol. A patient who
had used a five per cent, alcoholic solution for three days had an eruption
of bullar erythema annulatum of the palm and back of the hands, which,
however, disappeared within eight days after the applications were stopped.
In many cases of generalized hyperidrosis, even in consumptives, a one
or two per cent, solution of naphtol in alcohol gives relief.

I have treated three well-marked cases of hyperidrosis according to the

1883.]

Van Harlingen, Naphtol in Skin Diseases.

487

method just indicated, with, I must admit, very imperfect success. Two
of the three were very slightly if at all improved ; and the third case, a
very marked one, failed to report, and I am convinced did not benefit by
the use of the naphtol.

According to Kaposi, all varieties of tinea tricophytina are quickly cured
by means of naphtol. The application of a one per cent, alcoholic solution,
repeated four or five times in two or three days, or of the naphtol-sulphur
soap rubbed in and allowed to dry on the skin, desiccates the patches of
disease very rapidly. When the disease is extensive, the following appli-
cation can be made: R Saponis viridis, §j ; naphtol, gr. x; sp. lavan-

dulce, gr. 1. To be followed by the application of powdered starch. One
application every two or three nights is enough.

In tinea tonsurans, Kaposi has met with good results in the use of
naphtol after epilation.

My experience in the treatment of tinea tricophytina by means of naph-
tol leads me to a very moderate appreciation of the merits of the drug
for the destruction of this and the other vegetable parasites.

Case XIII. — In a case of tinea circinata menti, rapidly merging into
parasitic sycosis, an ointment of naphtol and vaseline, a drachm to the
ounce, was employed for several weeks entirely without effect, new patches
of disease appearing under the ointment. An ointment of double strength
(25 per cent.) was then substituted, but only with the effect of irritating
the skin.

Case XIV — In a second case of an almost precisely similar character,
a 25 per cent, naphtol ointment was used for between one and two weeks
with some slight improvement. A weak ammo'niated mercury ointment
being then substituted for the naphtol, speedy recovery took place.

In several mild cases of tinea circinata of the non-hairy portions of the
body somewhat better results were obtained.

Case XV. — A young man presented himself at my office with a half-
dollar sized ring of tinea circinata encircling the angle of the mouth on
either side. The disease was quite recent, and the very scanty hair was
not at all affected. An ointment containing eighty grains of naphtol to
the ounce of cold cream was prescribed. I then lost sight of the patient,
' but ten months later he came to consult me for some other affection of the
skin, when he informed me that the naphtol ointment had proved effectual
in removing the ringworm.

Case XVI — A lady applied at my office for the relief of a well-marked
and rapidly growing patch of tinea circinata the size of a silver dollar situ-
ated over the left scapular region. She was ordered an ointment of one
drachm of naphtol in an ounce of cold cream, and, although this was rather
negligently applied, the lesion was gone at the end of about four weeks.

Case XVII. — A young man came to the Polyclinic about the begin-
ning of July with a narrow, wavy line of tinea circinata extending across
the outer forehead, arching from the outer edge of one eyebrow to the outer
edge of the other. The disease was of about two months' duration, and
was spreading rapidly. An ointment of a drachm of naphtol to an ounce
of lard thoroughly applied cured the disease in about a fortnight.

488

Van Harlingen, Naphtol in Skin Diseases.

[Oct.

Kaposi does not mention the employment of napbtol in the treatment
of tinea versicolor. I have used it in six cases. In two of these, where
naphtol ointment the strength of one drachm to the ounce was employed,
the patients failed to report the result of treatment. In another case,
where the ointment was used faithfully for some time, no improvement
was shown. A fourth case improved slowly during a month while the
patient was under observation, but the treatment was given up as unsatis-
factory.

Case XVIII — A well-marked case of tinea versicolor, chiefly occupy-
ing the chest, but also to some degree the groins, was placed upon the
external use of sulphurous acid with sapo viridis, which removed the
eruption to all appearance completely. A relapse occurring, the patient
was ordered a naphtol ointment, one drachm to the ounce, which after six
weeks' use failed to work any perceptible benefit. He was then ordered
Vleminckx's solution, of which a four-ounce bottle sufficed to cure him.

The remaining two cases of tinea versicolor did better.

Case XIX., of eighteen months' standing, used the ointment of one
drachm to the ounce for twelve days, and at the end of that time reported
very marked improvement. In fact the disease had been entirely re-
moved at all points where the naphtol had been applied. The patient
was directed to employ the naphtol ointment more carefully and exten-
sively, but failed to report further progress.

Case XX., occurring in private practice, was that of a middle-aged
man, who had tinea versicolor of thirty years' standing. The naphtol
ointment used in this case was only half as strong as that used in the other
cases of tinea versicolor, being a half drachm to the ounce. After using
it for a week the itching, which had been a remarkable feature of the dis-
ease, diminished to a marked degree, and the patient declared he had
found no previous treatment of so much benefit. On examination, how-
ever, I failed to find very much improvement. After an absence of
several months, during part of which time the patient had used the naph-
tol with benefit, but had neglected it later, he returned with his skin
disease about as bad as ever. He was then ordered to use sapo viridis
with the naphtol ointment, and disappeared.

I have had no opportunity to employ naphtol in favus. Kaposi says
he has used a 1 per cent, oil, followed by naphtol soap, with great success.

The conclusion I draw from my experience with naphtol in the
treatment of the vegetable parasitic skin diseases is, that while it is a
parasiticide, and may be employed in some cases with success, it is much
less efficient than the ordinary parasiticides in present use, and possesses
no advantage whatever over them.

Kaposi says that pediculosis pubis is very satisfactorily treated by
means of a mixture of equal parts of olive oil and naphtol. It kills the
parasites completely, and has no disagreeable colour or odour like many
of the remedies employed. I have had no experience in the treatment of
this form of pediculosis by means of naphtol, but have recently employed
this formula in pediculosis capitis.

I have thus endeavoured to give some account of my experiments with

1883.] Van Harlingen, Naphtol in Skin Diseases.

489

this drug in the various affections for which it has been recommended by
Kaposi, and I may give my impressions as to its general value in a sum-
mary way, as follows : —

1. Scabies In naphtol we have one of the most efficient and agreeable

remedies for scabies which has as yet been brought forward. Both in the
rapidity of its action and in its beneficial effects upon the inflamed skin it
is superior to any of the means ordinarily employed for the cure of this
disease.

2. Eczema. — Well spoken of by Kaposi in eczema, naphtol has failed
in other hands to give the same beneficial results.1 In most cases of vesi-
cular and acute eczemas generally its action is simply that of an irritant.
On the other hand, it has a limited field of action in the cure of a certain
number of squamous eczemas of the scalp.

3. Prurigo Naphtol is highly extolled by Kaposi in prurigo, but I

have had no experience with it.

4. Ichthyosis. — Kaposi speaks well of naphtol. I have had no experi-
ence.

o. Psoriasis. — Naphtol is in my opinion a valuable addition to our
external means of treatment in psoriasis. Kaposi speaks well of it in
psoriasis of the scalp in particular, and my experience would lead me to
place it near chrysarobin and pyrogallic acid in effectiveness without the
neutralizing disadvantages of either of these drugs.

6. Seborrhcea In seborrhoea of the scalp naphtol is a decided addition

to our means of treatment. While inferior in some respects to sulphur or
carbolic acid, it has a certain range of usefulness which further experience
will in all probability more exactly demonstrate.

7. Acne, Acne-rosacea, Sycosis, and Lupus Erythematosus. — Kaposi
believes naphtol to be of benefit in each of these diseases. I have as yet
had no experience in their treatment by its means.

8. Hyperidrosis Naphtol is highly lauded by Kaposi in the treatment

of hyperidrosis, but in my hands it has failed entirely, although used
strictly according to his formulas. I consider it quite valueless in this
disease, as far as my experience goes.

9. Tinea Tricophytina Kaposi considers naphtol an efficient parasi-
ticide, but my experience leads me to regard its effects in ringworm as
inferior to those of almost all of the remedies at present used.

10. Tinea Versicolor I do not know of any experiments of Kaposi's in

the treatment of tinea versicolor by means of naphtol. My experiments
lead me to regard it as almost entirely inefficient in most cases.

11. Favus. — Naphtol is considered effectual in this disease by Kaposi.
I have had no experience, but am inclined by analogy to doubt its supe-
riority to remedies hitherto in vogue.

1 Possibly the employment of weaker preparations may induce a change in my views
on this subject. I have not yet had an opportunity to use these.

490 Cheesman, Periostitis of the Mastoid. [Oct.

12. Pediculosis — Kaposi finds naphtol a valuable agent in the treat-
ment of pedi-culosis pubis. I have had no experience here, but in a single
case of pediculosis capitis its action was favorable.

In conclusion, I Avish to guard myself from the imputation of too dog-
matic assertion as to the merits and demerits of the drug under considera-
tion. It is sometimes difficult to give full clinical evidence for one's
opinions, and I desire to say that my experience with naphtol extends
beyond the evidence I have given, and has perhaps somewhat influenced
my opinion as to the value of the drug. Its exact place in dermatic
therapeutics remains to be ascertained, but I am inclined to think it will
prove a not unimportant one.

Article XIV.

Periostitis of the Mastoid ; Necrosis; Recovery.
By Wm. S. Cheesman, M.D., of Auburn, New York.

On October 12, 1882, I was called to attend a gentleman, a;t. about
thirty, of not over-vigorous constitution, who had suffered from chronic
suppurative otitis media of the left side since an attack of scarlatina in
childhood. Some ten days before I saw him his old trouble underwent
an acute exacerbation, and after causing great suffering, the "gathering
broke," and much blood and a little pus poured out. Temporary relief
had been thus afforded, but pain soon returned. His physician, deeming
it unsafe to meddle with the ear, had left the case to nature.

Physical examination showed the external auditory canal to be much
swollen; within all was pus. Discharge had, however, ceased. No air
could be forced through the Eustachian tube by Politzer's method. Hot
douches every three-quarters of an hour, anodynes at night, leeches to
the tragus and the mastoid, all failed to give relief or secure sleep. The
pain was sometimes lancinating, sometimes throbbing, and in addition
there was a severe neuralgia of the occipitalis major nerve and of some
branches of the trigeminus.

lUh. 'Slight swelling and tenderness of the mastoid began, which by
the 16th had so much increased that the auricle protruded at an angle of
45°, being itself greatly . swollen. The temperature ranged at 101° in
the evening. Wilde's incision seemed to offer a good prospect of relief,
but in a consultation held that afternoon it was thought best to continue
poulticing., and to await the formation of pus.

20th. Fluctuation was detected behind the ear on a level with the upper
wall of the external auditory canal. The hypodermic here drew pus.

1583.]

Cheesman, Periostitis of the Mastoid.

491

Anaesthesia of the skin having been produced by the ether spray, an in-
cision was made, and half an ounce of fetid pus evacuated. At the bottom
of the wound the probe detected bare bone over a space about one inch
square. The wound was douched with hot carbolized water, and a drain-
age tube inserted. Relief from pain was immediate, and the patient slept
all night for the first time in two weeks.

Under the use of hot douches and poultices the swelling rapidly sub-
sided, and on the 23d, the middle ear was inflated by Politzer's syringe,
and the perforation of the drum located in the posterior inferior quadrant.
With a loud whistling sound the compressed air forced through it a gela-
tinous material into the external auditory canal.

Within a couple of weeks the patient was able to go out. The ear was
douched and the wound cleansed twice a day. The area of bare bone
became rough, and granulations pouted about the mouth of the wound in
the manner characteristic of necrosis ; but no bone loosened. Dilute aro-
matic sulphuric acid was used as an injection with a view to dissolving the
dead bone. It was deemed unwise to attempt to check the middle-ear
discharge till the mastoid trouble should be passed.

All went well until the middle of December. The discharge then became
scanty, the patient had chilly feelings, his bones ached, and he vomited.
The meatus was swollen and nearly closed ; the left cervical glauds be-
came indurated and tender; the evening temperature ranged' at 101°.
At the same time, I found that the probe introduced through the drain-
age track did not move freely over the necrosed surface, and it was thought
that granulations had sprung up and shut off a portion of that surface,
damming in pus. Accordingly, the patient was etherized, the wound en-
larged, and the whole area of bare bone exposed. It was found that the
track in which the drainage tube had been inserted had adhered to the
bone immediately at its bottom, and that thus the space around had been
shut off from drainage. The whole necrosed area was then scraped bare
of a few flabby granulations, and, by means of a dental engine, burred
away till the bone was seen to bleed, and a smooth and apparently healthy
surface remained. I hoped that the tedious process of exfoliation might
thus be prevented, and that, living bone having been reached, the wound
might granulate from the bottom. This was therefore packed with cotton
soaked in balsam of Peru, and poulticed. The temperature range at once
became normal, and in a few days swelling subsided and appetite re-
turned. The usual douches of the ear and wound were resumed.

For three weeks it seemed that my hopes were not ill-founded. Granu-
lations formed rapidly over the burred surface, and the patient was able to
ride and walk out. But on the 3d of January I found the external audi-
tory canal again swollen, the patient complaining of nausea, and the tem-
perature at 100°. Exploration among the granulations detected a pus
cavity leading toward the auricle. Though this was thoroughly, cleansed

492

Chessman, Periostitis of the Mastoid.

[Oct.

and packed, the symptoms were not relieved. On the 6th the swelling in
the auditory canal pointed and was cut, some pus being evacuated. The
same day a probe introduced among the granulations at the bottom of the
wound entered, greatly to my surprise, the mastoid antrum. How this
opening into the cells had occurred, I could not divine. No loose frag-
ments of bone had ever been felt by the probe, and none had been dis-
covered in the discharges ; and yet a portion of the outer wall of the
antrum had come away. The process could not be termed exfoliation ;
no flake of bone was ever known to have separated. It seemed rather a
disintegration, ulceration ; molecular death and removal going on imper-
ceptibly, till the outer wall of the mastoid chamber was perforated. No
pus was found within, nor did the antrum or the cells ever become im-
plicated.

During the night of January 7th, the patient had a rigor, and another
pocket of pus was found in the anterior wall of the wound. The next
day, January 8th, Dr. John Van Duyn, of Syracuse, saw the patient witli
me. He was etherized, the old incision continued downward to the tip of
the mastoid process, a track formed from the lower end of this cur, pass-
ing between the auricle and the skull, to the periosteal abscess in the
external auditory canal, and strands of silk soaked in carbolized wax
inserted as a tent. The cut itself was packed with cotton soaked in car-
bolized oil, and poulticed. The temperature now rapidly fell to normal,
and swelling and tenderness disappeared. The drainage track above de-
scribed was syringed twice a day, the water escaping from the external
meatus. Iodoform was freely used in the dressings.

From this time progress to recovery was well-nigh uninterrupted, granu-
lations growing from the bone, and filling the wound compactly from the
bottom. They were repeatedly trimmed down, in order to insure against
possible pocketing of pus. Once such a cavity was discovered among
them, but when it had been opened and cleansed the symptoms due to it
disappeared. It became necessary in about a month to remove a granu-
lation mass that sprouted from the drainage sinus at its entrance into the
auditory canal, nearly occluding that passage. This was easily done by
means of Bosworth's modification of Wilde's snare. The patient was
discharged cured April 28, 1883, nearly seven months after the begin-
ning of his sickness.

1883.J

493

REVIEWS.

Art. XV. — Spinal Concussion.

Injuries of the Spine and Spinal Cord without Apparent Mechanical
Lesion and Nei^vous Shock, in their Surgical and Medico-Legal As-
pects. By Herbert W. Page, M.A., M.C. Cantab., Fellow of the
Royal College of Surgeons of England, etc. Philadelphia : P. Blakis-
ton, Son & Co., 1883.

In 186G a volume, entitled Six Lectures on Certain Obscure Injuries
of the Nervous System commonly met with as the result of Shocks to the
Body received in Collisions on Railways, was published by the great Eng-
lish surgeon, Erichsen. Jn 1875 these lectures were expanded into a
larger work on Concussion of the Spine, which, at the time, attracted
widespread attention, and lias since been regarded in many quarters as
high authority, both surgical and medico-legal. The acknowledged emi-
nence of its author, and the evidence of investigation of surgical literature
and of personal experience shown by the book itself, gained for it a foothold
which it still largely maintains. The second edition is before us as we
write, and we remember reading the first with much pleasure, and turning
to it with avidity when, by good or bad chance, an. admiralty case fell into
our hands as expert. It should certainly receive the hearty endorsement
of some socialistic convention, for it has proved one of the greatest prac-
tical enemies of corporations, taking money without stint from their coffers
— money for litigants, for lawyers, and for experts.

Since the publication of Mr. Erichsen's volume " spinal concussion" has
not infrequently been treated at greater or less length in journals and
general works on surgery or neurology, most writers, but not all, following
blindly in the wake of Mr. Erichsen. The volume of Mr. Page, which
forms the basis of the present review, is, however, as far as we know, the
first systematic attempt to discuss thoroughly the subject in surgical and
medico-legal aspects.

This work will prove of great service. It is a highly practical con-
tribution to medicine and surgery. The author has acted for a num-
ber of years in the capacity of surgeon to the London and Northwestern
Railway Company, and therefore has had abundant opportunities to be-
come practically acquainted with the subjects which he discusses. A
large part, but by no means all of the book, constituted the Boylston Medi-
cal'Prize Essay of 1881. Notwithstanding the author's connection with
a great corporation, the charming spirit of justice to all, which pervades
the volume, makes us feel that he has written, as he claims, without any
spirit of partiality or bias, and that, although his experience has been, for
the most part, gained while acting as surgeon to a railway company, there
has been nothing whatever in the circumstances of his appointment to im-
pair, even in the very smallest degree, that free and perfect independence
which is the rightful possession of a medical man. His work is worthy of

494

Reviews.

[Oct.

all commendation, and will, no doubt, rank in the future with those stand-
ard volumes which lawyers and medical experts delight to consult and
ponder on in preparation for the exigencies of a trial for damages for rail-
way or similar injuries. We have deemed it worthy of a somewhat
extended analysis.

The importance of the topics discussed will be better appreciated when
the frequency with which injuries of the spine, or supposed injuries of
the spine, become the subjects of arbitration, or judicial investigation is
fully recognized. Mr. Page points out that injuries of the back more
often become the subject of medico-legal inquiry than any other kinds of
injury to which man is liable. Of 250 cases, which constituted the whole
number in one of his note-books, no fewer than 145 complained of their
backs or their " spines." He refers to a similar observation by Rigler, a
German writer, who gives statistics which show that since the passing of
a law in Germany for the compensation of injured persons on railways the
number of injuries or complaints of injuries had enormously increased, and
that, moreover, of thirty-six complaints of injury no fewer than twenty-
eight were of the back.

Railway and other corporations are, by no means, the only financial
sufferers from the popular doctrine of " spine disease" and " spinal con-
cussion." Among those who manage to live a large portion of their time
on the charity of benevolent and beneficial societies the "spine" cases
form a large contingent, as our own experience during a few years has
abundantly shown ; and in claims for pension by old soldiers — many of
them "old soldiers" in the proverbial sense — the "spine" is found to be
a convenient portion of the body to localize not a few of those ills which
have had their origin as much in the overflowing generosity of Congress
as in the accidents and incidents of war.

In Chapter I., at the very outset of his inquiry, Mr. Page seeks to learn
how far the spinal cord is really liable to injury. He at once, of course,
acknowledges the grosser lesions of the spinal column and cord, from ter-
rible accidents, which have been as well enumerated by Sir Benjamin
Brodie as by almost any author since his time ; for example, fractures
without displacement, fractures with depression or displacement, and caus-
ing pressure on the spinal cord, fractures complicated with dislocation,
dislocations not complicated with fracture, extravasations of blood on the
surface of the membranes of the spinal cord, narrow clots of blood within
the substance of the spinal cord, and laceration of the spinal cord and its
membranes.

He quotes and discusses the views and reported cases of Brodie, Aber-
crombie, Sir Charles Bell, Mayo, Boyer, and Lidell, clearly sustaining
the position that in the serious cases of spinal injury attributed to " con-
cussion of the spine," some gross lesion, as hemorrhage, fracture, disloca-
tion, twisting of the cord, or wounding of great nerve-trunks, has most
probably occurred. Evidences of such lesions cannot always be had during
life, and post-mortem examinations are often imperfectly performed.
Even recoveries, or partial recoveries, are as explicable from this stand-
point as from that of the mythical concussion. Extravasated blood is
sometimes absorbed, and recoveries may take place even after dislocation
of the vertebra?. In a final note, Mr. Page gives from the Lancet the
record of two remarkable cases, which appeared after the chapters of his
book were made ready for the press. The first is a case of " dislocatioi.
of the fifth cervical vertebra, with reduction and recovery," under the

1883.]

Page, Injuries of the Spine and Spinal Cord.

495

care of Mr. T. H. Ceely, in the Royal Bucks Infirmary. The second is
reported as " a case of recovery after a broken neck," by Mr. C. Jorclison,
of Malpas.

The analogy between "concussion of the brain'5 and so-called "con-
cussion of the spinal cord" is examined. We accord entirely with the
opinion of Mr. Prescott Hewett, quoted by Mr. Page, that it still remains
to be demonstrated that concussion may prove fatal without leaving a
trace of injury to the brain-substance. Even in cases of recovery lesions
may have occurred, and have been gradually repaired.

It has seemed to us that Mr. Page has devoted too little attention to
the views of M. Duret. He confines himself to a single remark, that M.
Duret regards the phenomena of concussion as due to change in the tension
of the cerebro-spinal fluid rather than to any effects upon the cerebral
mass itself. M. Duret's physiological experiments and opinions were ably
summarized and reviewed in the American Journal of the Medical
Sciences for January, 1879, and need only be very briefly alluded to at
present. Seeking for the cause and mode of production of concussion of
the brain, he found that severe blows upon the head, sufficient to depress
but not to fracture the skull, so acted upon the hemispheres and the
cerebro-spinal fluid as to cause that portion of the latter contained within
the lateral ventricles to pass suddenly through the aqueduct of Sylvius
into the fourth ventricle, causing the latter and sometimes the central
spinal canal to be dilated or even ruptured, and thus bringing about the
phenomena of cerebro-spinal shock.

M. Duret showed that lesions, chiefly in the form of hemorrhagic foci,
were produced in cases of concussion by peripheral and ventricular waves
of the cerebro-spinal fluid. There hemorrhages were found on the con-
vexity of the hemispheres, at the base of the brain, in the floor of the
fourth ventricle, in the substance of the medulla and pons, and even at
different points of the spinal cord. One case' of traumatic locomotor
ataxia is reported, caused by a blow on the side of the head, the lesion
consisting of an extravasation under the pia mater covering the posterior
columns. Accepting these views we have an explanation of otherwise
obscure cases ; not from spinal, but from cerebral or cerebro-spinal con-
cussions, the lesions, however, being really gross.

The very first paragraph of Mr. Eriehsen's book contains, we think, the
expression of an erroneous opinion. Comparing injuries to the head and
to the spine, he asserts that if the brain is liable to suffer serious primary
lesion and protracted secondary disease from the infliction of slight and
perhaps, at the time, apparently trivial injuries to the head, the spinal
cord is at least equally prone to become functionally disturbed and organi-
cally diseased from injuries sustained by the vertebral column. On the
contrary, clinical and pathological experience both sustain Mr. Page in
the view which he confidently expresses, that, with very rarest exception,
the spinal cord maintains its supremacy as the most securely protected of
all the organs of the body.

• The spinal cord is infinitely better protected from the effects of blows
and jars than the brain ; its special attachments, its paddings and buffers,
the very thick walls of its bony canals — serve to guard and defend it
almost impregnably.

Mr. Page is unable to find cases of concussion, injury of the spinal
cord, without real gross damage to cord or column, comparable to cases
of concussion of the brain. Even if the analogy in any case holds good,

496

Reviews.

[Oct.

it is only in the very rarest instances that it can be unequivocally main-
tained." He thinks it highly improbable that the spinal cord should be
especially liable to suffer injury in railway collisions, no matter how trivial
they may be, and even though no damage has been inflicted on or near the
spinal column.

Chapter II. of Mr. Page's book is devoted almost entirely to an analysis
and criticism of Mr. Erichsen's views on so-called " concussion of the
spine." He begins, and very properly, by finding fault with the title
" concussion of the spine." The term " spine" is by some applied to the
vertebral column ; by others to the contents of the spinal canal ; by still
others to both the case and its contents.

" And to employ for the common injuries received in railway accidents a title
which may now mean this, and now that, and very often may mean nothing at
ail, is to run a risk, it seems to us, of either playing into the hands of those who
are using dishonest means to enhance their claims, or of seriously misleading
those who, from lack of experience and opportunity, are ignorant of the symp-
toms and pathology of diseases of the spinal cord."

We will now put in contrast the views of Mr. Erichsen and Mr. Page
by a few selected quotations. Mr. Erichsen speaks of " concussion of the
spine" as follows : —

"It is a phrase generally adopted by surgeons to indicate a certain state of the
spinal cord occasioned by external violence — a state that is independent of, and
usually, but not necessarily, uncomplicated by, any obvious lesion of the verte-
bral column, such as its fracture or dislocation, a condition that is supposed to
depend upon a shake or a jar received by the cord, in consequence of which its
intimate organic structure may be more or less deranged, and by which its func-
tions are certainly greatly disturbed, so that various symptoms, indicating a loss or
modification of innervation, are immediately or remotely induced."

The following quotations may serve to give an idea of the views of
Mr. Page :—

"When we meet with paraplegia occurring after severe injuries to the spine,
and there be no direct evidence of damage thereto, there is yet strong presump-
tive evidence, from the lessons of the dead-house, that the vertebral column has
itself been severely injured, and that from the immediate consequences of such
injuries the function of the spinal cord has been annulled and destroyed.

" Used now to indicate this injury, and now that, here signifying the cause,
there the effect, by a writer so distinguished as Mr. Erichsen, it is little wonder
that a wider application even has been given to the term, and that, as we shall
see by and by, ' concussion of the spine' is used almost indiscriminately both in
and outside the medical profession to indicate the injuries which are received in
collisions and which become the subject of medico-legal inquiry, although the
spinal column and its contents have met with no damage at all. It appears to us
nothing less than lamentable that, in laying before the profession and the world
the results of his experience upon this subject, and writing from the high vantage
ground of an assured position, both as a surgeon and as a teacher of surgery, Mr.
Erichsen should not have been more clear, more explicit, and less ambiguous in
the use of the phrases which he has employed."

' ' As has been abundantly pointed out in the preceding pages, there is but
scanty proof of the liability of the spinal cord to suffer from concussion, pure and
simple, in the absence of simultaneous injury to the spinal column, the excep-
tional cases being extremely rare.

" And if uncomplicated 'concussion' lesions be so exceptional, and the spinal
cord be, as we believe the common experience of surgeons proves it to be, the
most securely protected of all the organs of the body, it seems most improbable
that it should be prone to incur lesions due solely to indirect and general concus-
sion."

1883.] Page, Injuries of the Spine and Spinal Cord.

497

The weakness of the cases used by Mr. Erichsen to illustrate and sub-
stantiate this doctrine of "concussion of the spine" is really astonishing,
as Mr. Page amply demonstrates.

In attempting a pathological explanation of " concussion of the spine,"
Mr. Erichsen, as Mr. Page shows, is as unhappy as in some of his other
efforts.

" The primary effects of these concussions or commotions of the spinal cord,"
he says, "are probably due to molecular changes in its structure. The second-
ary are mostly of an inflammatory character, or are dependent on retrogressive
organic changes, such as softening, etc., consequent on interference with its nu-
trition."

The phrases " molecular changes," " molecular disturbances," are sim-
ply made to do duty for ignorance. The nervous system is so constituted
that even a jar, shake, or concussion, is more likely to produce vascular
than " molecular" lesions, if by the latter is meant change in nerve-cell
or fibre.

Mr. Erichsen concludes that the whole train of secondary nervous phe-
nomena arising from shakes and jars of, or blows on, the body, characteristic
of concussion of the spine, are in reality due to inflammation of the spinal
membranes and cord. What proof of this pathology has ever been pre-
sented ? It is a remarkable fact, that Mr. Erichsen himself is acquainted
with only one case with a post-mortem record ; and inquiry as to the
merits of this particular case is not very encouraging to his peculiar views.
From a careful reading of this case, it would seem likely that it is an in-
stance of posterior spinal sclerosis, the collision and the coming in of the
disease being probably simply a coincidence.

In more than one place, and by convincing argument and illustration,
Mr. Page shows the utter fallacy of the wide-spread, yet erroneous, im-
pression both throughout the profession and the laity that the effects of a
railway collision upon the spinal column or cord are most likely to be
remote.

" Our inquiries," he says, " have either been singularly unsuccessful, and they
have been made by direct oral and written communications with many profes-
sional brethren in all parts of the country — or we must admit that secondary and
remote degeneration of the spinal cord, in cases where there has been no distinc-
tive evidence of injury, is very rare indeed. We say distinctive evidence, for we
hold that we cannot include amongst injuries to the spinal cord those molecular
disturbances which must affect every tissue or organ in the body when subjected
to any severe general shake or jar. Molecular disturbance is not necessarily
molecular disintegration or pathological change, and there is no evidence to show
that molecular disturbance is in itself a grave condition, or likely to have evil
results, unless there should have been at the time some well-marked pathological
lesion such as might post mortem be discovered by the eye. Were ' molecular
disturbance' to be followed by pathological change as a direct result thereof,, the
consequences of unnumbered slight injuries would be serious indeed."

Injuries to the muscular and ligamentous structures of the back and of
the spinal column are frequent causes of the real symptoms which are pre-
sent after railway collisions. Mr. Page holds from experience, and from
the arguments which he has heard about individual cases, that real but
comparatively favourable injuries of this kind combined with the symp-
toms of general nervous prostration or shock have laid the foundation for
the erroneous views so largely entertained as to the nature of the com-
mon injuries of the back received in railway collisions. Pain on move-
No. CLXXIL— Oct. 1883. 32

498

Reviews.

[Oct.

ment, tenderness on pressure, pseudo-paralysis the result of a fear of
moving, want of freedom in micturition, and a constipation which simu-
lates paralysis of the bowels from lack of the support and help which the
lumbar muscles usually provide, conjoined with great mental disturbance
from shock, lead the patients to feel that they have been stricken with
some terrible spinal catastrophe from which they may never recover.

Dr. R. M. Hodges, quoted by Mr. Page in a foot-note, has called
attention to these sprains of vertebral ligaments and ruptures of the apo-
neuroses and muscles of the back, as causes of the phenomena assumed to
be those following concussion of the spinal cord.

"They give rise to much local pain, to a rigidity of the spine, a difficulty in
rising from the seat, a stiffness in walking, and contribute readily to any disposi-
tion on the patient's part to make much of his injury. The attitude, or the cau-
tious and constrained movements of the body, may be made to suggest inferences
which cannot be too guardedly accepted."1

The spinal nerves are sometimes injured by strain or direct contusion
in railway and similar accidents. Hilton, quoted by Mr. Page, in his
work on Hest and Pain, speaking of a man falling with his back upon
the ground, says : —

"It is possible that the spinal marrow, obeying the law of gravitation, may, as
the body falls, precipitate itself in the same direction, fall back towards the arches
of the vertebra?, and be itself concussed in that way. Or the little filaments of
the sensitive and motor nerves, which are delicately attached to the spinal marrow,
may for a moment be put in a state of extreme tension, because, as they pass
through the intervertebral foramina, they are fixed there by the dura mater, and
if the spinal marrow be dragged from them, the intermediate parts must be neces-
sarily put on the stretch, producing at the time the pins and needle sensation, and
also explaining the symptoms felt on the following day."

Mr. Page refers to a point of great practical moment to those whose
duty it may become to examine cases claiming damages for spinal injury,
namely : —

" The importance of learning and paying due regard to the precise history of
the accident and of the injury, so that we may escape from the region of cloud-
land where we hear no more than that a man has been in a collision, and had
concussion of the spine and become paralyzed."

The real value of pain in the back as an indication of serious disease is
fully discussed. This symptom is almost invariably present in the rail-
way cases ; and in the vast majority of cases, when it is not due to mus-
cular or ligamentous strain, it is hysterical or imaginary, and nothing
else.

It is a remarkable fact that Mr. Page, with his large experience, has
met with no case where spinal caries and ultimate curvature have been
produced by injury to the back in a collision.

Our own experience is in accordance with that of Mr. Page, with refer-
ence to the traumatic origin of tabes dorsalis. We have met with but
few cases where any direct relation could be traced between an injury and
the origin of ataxic symptoms, although, in the light of M. Duret's ex-
periments, we admit the possibility of such an occurrence.

Two chapters (IV. and V.) are devoted to the consideration of " shock
to the nervous system," as seen after railway collisions. Very wisely he

1 Boston Medical and Surgical Journal, April 21, 1881.

1883.] Page, Injuries of the Spine and Spinal Cord.

499

begins his discussion* of this subject by explaining the sense in which he
uses the expression shock to the nervous system, namely, as a term ap-
plicable rather to the whole clinical circumstances of the case than to any
one symptom which may be presented by the injured person. The very
lack of precision in the phrase appears suitable to describe the class of
cases considered, the course, history, and general symptoms of which in-
dicate some functional disturbance of the whole nervous balance or tone,
rather than structural damage to any organ of the body.

Three classes of cases of nervous shock, not including those in which
a fatal issue rapidly ensues, are discussed and illustrated: (1) Cases of
undoubted collapse from the bodily injury received and from the very dis-
tressing surroundings of the accident ; collapse or severe shock both from
bodily and mental causes. (2) Cases in which the accident has been less
severe in its effects upon life and limb, and where the earliest effects of
shock have been comparatively slight ; here mental predominate over
physical causes, although both may be present, and the cases are genuine.
(3) Cases which have no history whatever of injury or of the symptoms
of collapse, no faintness, nausea, or vomiting, no early reaction from an
initial stage of depression, but where the after-history very closely simu-
lates that of the second class of cases ; these are examples of spurious
nervous shock.

Mr. Page discusses briefly the cases of profound shock or collapse from
severe and sudden injuries, whether inflicted upon the head or upon some
other part of the body, the condition about which the surgeon usually asks
first in cases of grave accident. He does not enter at length into the
pathology of shock, stopping only to speak in terms of highest compliment
of the very able account of shock in all its bearings, in the International
Encyclopedia of Surgery, by Mr. C. W. Monsell-Moulin, who sums up
the results of experimental physiology by saying that " shock is an exam-
ple of reflex paralysis in the strictest and narrowest sense of the term — a
reflex inhibition, probably in the majority of cases general, affecting all
the functions of the nervous system, and not limited to the heart and
vessels only."

Great stress is laid upon the element of fear in railway collisions in
inducing immediate and serious collapse, and in giving rise to the trouble-
some after-symptoms in the cases which recover from the first shock. He
tells the following interesting story : —

" How largely fright may of itself be a condition recognized as shock is well
shown by a case communicated to us by a surgeon of large experience, who, sum-
moned to a railway station to see and conduct to the hospital a railway servant
who had had his foot, as was supposed, run over on the line, found him in a state
of collapse, and in greatest alarm as to the injury to his limb. Upon examina-
tion it was discovered that the only damage was the dexterous removal of the
heel of his boot by the wheel of a passing engine."

The various symptoms which are commonly met with in genuine cases
of protracted nervous shock, whether that shock has been due to bodily
injury, excluding concussion of the brain, or where the bodily injury has
been but trifling, and the mental shock severe, are set forth at length by
Mr. Page. In the light of these symptoms, instead of "railway-spines,"
many of the cases under discussion had better be termed "railway-brains."
Headache, sleeplessness, altered pulse and heart-beat, nervousness, asthe-
nopia, and loss of memory are by no means spinal ; and even paralysis,
anaesthesia, and spasm, whether functional or organic, are as likely, or, on
the whole, more likely to be cerebral than spinal.

500

Reviews.

[Oct.

The happily conceived term " litigation symptoms" is applied to many
of the manifestations which follow accidents by railway. Differences of
opinion arise between those who have to receive and those who have
to provide compensation ; litigation ensues and the plaintiff is subjected
to the delays, anxieties, and worries of a lawsuit. Patients rarely return
to work so long as the question of compensation and the possible disputes
attending it remain unsettled. Want of occupation, and sometimes of
exercise, leads to wretchedness both of body and mind. Comparing a
railway patient waiting for compensation with another, a hospital patient,
whose state is as nearly similar as may be, and who is compelled to re-
sume work as soon as possible, the latter gets well, the former lingers
month after month.

Mr. Page cites several cases in his Appendix to show that, in serious
injury to limb, such as fracture, even if there be extreme collapse at the
time of the accident, it is most unusual to meet with the protracted after-
symptoms which have been described as due to general nervous shock.
The reasons for this are that the injury is precise, definite, and not ob-
scure, complete rest is enforced, and there is but little likelihood of dis-
pute arising as to compensation. " Litigation symptoms" are absent,
because litigation is not needed.

To bromide of potassium is attributed the prolongation of the illness
and delay in convalescence in some cases. Very properly is the whole-
sale use of this drug in almost any and every kind of nervous disorder
denounced. " It is not by a lavish use of bromides," says our author,
"that success in the treatment of neurasthenia, to which many of the cases
of railway shock are so nearly allied, is being obtained, even in the most
extreme cases, by Weir Mitchell, Playfair, and many others."

In Chapter VI. Mr. Page discusses a class of cases occurring after rail-
way and other injuries which he believes should be placed in the same
category with those described so ably by Sir James Paget, under the
designation neuromimesis or nervous mimicry of organic disease. Many
of Mr. Erichsen's " spinal concussion" cases undoubtedly belong here —
are functional or neuromimetric disorders. It must be said, in justice to
this eminent surgeon, that he does not overlook the fact of such affections
occurring in connection with railway cases. In Lecture VIII. of his
work, under the head of spinal ancemia, hysteria, shock, and unconscious-
ness, as consequences of concussion of the spine, he recognizes fully the
fact of the occurrence of hysterical and allied affections after raihvay acci-
'dents ; he also discourses briefly on those forms of mental or moral shock in
connection with those accidents. With Mr. Page, w^e believe, however,
that he sometimes confounds cases of hysteria or neuromimesis with his
concussion of the spine. With him, wre also believe that very often these
functional disorders are mistaken for real structural disease, and that they
are very common after railway collisions, when the nervous system has
been brought into that state which is the fit soil for their development and
growth.

Sir James Paget's views of the existence of a peculiar nervous tempe-
rament in cases of hysteria or nervous mimicry, whether in connection
with traumatisms or arising independently of these, are reiterated and
amplified by our author. Neuromimesis is a localized manifestation of a
certain constitution.

" As to what is verily the peculiarity of the nervous constitution, I believe we
have nothing fit to be called knowledge. It is even hard to give fit names to

1883. J Page, Injuries of the Spine and Spinal Cord.

501

what we may suppose it to be. We may speak of the nervous centres being
too alert or too highly charged with nerve-force, too swift in material influence,
or too delicately adjusted, or defectively balanced. But expressions such as these,
or others that I see used, may be misguiding. It is better for us to study the
nervous constitution in clinical facts." (Paget.)

Chapters like these teach the great practical importance of investiga-
tions like those embodied in Dr. Tuke's work on the Influence of the
Mind on the Body, although not written with any such intention. Many
of the cases recorded by Mr. Page largely, if not entirely, psychical in their
origin, are kept up or made worse by a mixture of hope and uncertainty
as to the result of litigation threatened and impending, and are eventually
cured by the mental influence of the settlement of the claim ; nor are
many of these cases unreal or undeserving of some compensation. It is
difficult to make some hard-hearted and unemotional people believe to how
great an extent fright, anxiety, and similarly mentally acting influences
may produce serious temporary or even more or less permanent results. A
series of interesting cases of functional or neurometric disorders following
railway collisions are detailed.

Although not referred to by Mr. Page, Skey, in his admirable lectures
on "Hysteria,"1 as far back as 1866, forcibly called attention to these
cases.

"The light of improved knowledge," he says, "will dissolve the mysteries
which daily surround these cases in the form of supposed spinal concussions, par-
tial paralysis, effusions into the theca vertebralis, thickening of the membranes
of the brain, spinal cord, and lesions of this organ or that. These, as Dr. Sy-
denham declares, are but imitations and resemblances, and not realities, and that
they deceive the multitude is undoubted. When real disease prevails, there is
no difference of opinion among medical men as to its existence."

The chapter on Malingering is equally interesting with the other chap-
ters of this interesting book. A distinction is clearly drawn between
cases due to shock to the nervous system, neuromimetric disorders, and
cases of malingering. The remarks about feigned and fictitious diseases
in general are of value.

"Depend upon it," he says, " if a man has not known disease at the bedside,
if from want of familiarity with disease he cannot rightly weigh and balance its
different symptoms and signs, he will be almost certainly deceived when a case
of fictitious disease comes before him."

The frequent assumption of injury of the " spine" by malingerers is
pointed out in strong terms, and by apt illustrations.

A few hints as to the investigation of the oftentimes trying cases dis-
cussed by Mr. Page, may prove of service.

Take nothing for granted. Assume, without necessarily allowing the
patient to know it, an attitude of scientific criticism. Carefully separate
subjective from objective symptoms, and if, on close scrutiny, the latter
are practically wanting altogether, a feeling of healthy scepticism should
not be restrained. Let the first object be to determine whether or not
any real organic lesion of the cerebro-spinal mass in its envelops has
occurred. Always follow a systematic plan of examination, never jump-
ing to conclusions ; but investigating by successive steps for disturbances
of sensibility and mobility ; for reflex, vaso-motor, trophic, urinary,

1 Hvsteria, etc. Six Lectures delivered to the Students of St. Bartholomew's Hos-
pital, 1866. By F. C. Skey, F. R. S. London, 1867.

502

Reviews.

[Oct.

sexual, ocular, and other changes. Once satisfied of the non-existence of
serious organic lesion, next differentiate fraud or malingering from uncon-
scious neuromimesis.

Mr. Page has not contented himself with a mere citation of authori-
ties and arguments from general principles. Valuable original cases are
found scattered through the book ; and in an appendix he gives a care-
fully prepared table which contains, inclusive of those recorded in the
text, two hundred and thirty-four oases. The table shows the sex and age
of the patient, the nature of the accident, a general outline of the case,
the date of settlement of claims, the time when last heard of after the
accident, the condition at this period, the evidences of injury to the spinal
cord and membranes, and general remarks. The cases forming the table
are not selected. He simply has chosen the first two hundred and fifty
cases of his note-book, and excluding therefrom those cases where injury
had been sustained in some other way than in collision, twro hundred and
thirty-four remained.

If our author enforces one general truth more than another, it is that
of the folly of trusting too much to appearances. He relates the follow-
ing case : A man based a large demand for compensation from a railway
company on stiffness of his elbow and inability to move his arm, the
result of a collision. A verdict incommensurate with his expectations
having been recorded, he threw up his arms and exclaimed : " My God !
I 'm a ruined man !"

Mr. Sergeant Ballantine, in his entertaining Experiences of a Barris-
ter's Life, speaks of two cases in which he was engaged, and in both of
which justice miscarried through trusting too much to appearances.
These reminiscences are so appropriate to the subject in hand that we may
be pardoned for recalling them in concluding this review.

" A gentleman named Glover was the plaintiff in the first of the two cases to
which 1 have called attention. He had been, I believe, member for Reading,
and, although no external injury was apparent, it was stated that he had received
a serious spinal shock, and that the result might be fatal. His appearance, how-
ever, in the witness box did not support this idea, and his manner prejudiced his
case' exceedingly. It was finical and coxcombical, and many, of whom I confess
myself to have been among the number, thought that he was not candid in giving
his evidence ; and the statements of the doctors, which gave a very grave aspect to
the alleged symptoms, had in consequence less weight than they deserved. Lord
Campbell took an unfavourable view, and evidently thought that there was gross
exaggeration. The jury, coinciding in this opinion, returned a verdict quite in-
adequate to the injuries it truly represented. AVithin three months the unfortu-
nate gentleman, a comparatively young man, died, and it could not be doubted
that his premature death resulted from the effects of the injuries he had under-
gone, and which had been correctly indicated by the medical men."

4 ' In the other case, tried, I believe, before the same judge, the plaintiff was
brought into court apparently in a moribund state. He seemed scarcely able to
articulate, and his limbs were without power or sensibility. According to the
doctors, and I do not impugn their truth as to the fact, his powers of sensation had
been tested by a needle, which had been inserted in his arm without his exhibit-
ing any sign of feeling ; in fact, he created general sympathy, and obtained a
very large verdict amounting to many thousands. It was thought useless to
move for a new trial. Within a week after the time had elapsed for doing so the
plaintiff was recognized climbing Snowden in full activity and strength, and
within the twelvemonth was presented with an heir who, thanks to his father
having been so nearly killed, was likely to have something to inherit."

C. K. M.

1883.]

Saint Thomas's Hospital Reports.

503

Art. XVI. — Saint Thomas's Hospital Reports. New Series. Edited
by Dr. Robert Corey and Mr. Francis Mason. Vol. XI. 8vo.
pp. xvi., 419. London : J. & A. Churchill, 1882.

The Saint Thomas's Hospital Reports for 1882 is a goodly sized vol-
ume, and is freighted with a number of excellent clinical papers. Ap-
pended to it are the statistics for the years 1880 and 1881, the former
having been crowded out of the preceding volume by the pressure of the
work done for the International Medical Congress. But the volume
before us is thus rendered doubly interesting by the diversity of the sub-
jects of which it treats.

The opening article, on Disease of the Aortic Valves probably origi-
nating in Malformations, is from the pen of the late Dr. Thomas B.
Peacock, and has attached to it the additional interest of being probably
his last contribution to medical literature. An appended plate shows the
heart in cross-section, with a satisfactory indication of the post-mortem
valvular appearances, which are thus described : —

"The right and posterior aortic segments were blended together, so that the
aortic orifice had only two valves, and both of them were much thickened, and
the united curtain dropped below the level of the other curtain, so that there was
both obstruction to the flow of blood from the left ventricle into the aorta and
regurgitation from the vessel into the ventricle."

It is also a matter of interest to note the physical signs produced by
this condition during life : —

" The action of the heart is tumultuous and visible over a large space ; there
is decided prominence in the prascordial region. The dulness on percussion
begins at the second interspace, and becomes entire at the third. Laterally it
commences to the right of the sternum, and extends beyond the line of the left
nipple. At the base there is a systolic murmur, heard most distinctly at the
right side and upper part of the sternum ; it is short and rough, and is followed
by a soft diastolic murmur, which is propagated down the course of the sternum.
Toward the apex there is a Creaky murmur, which is clearly of independent
origin and may be presystolic. It is not heard posteriorly. There may be a
slight purring tremor felt at the apex."

Dr. Peacock concludes his paper by a resume of the points which lead
him to attribute the disease of the valves to malformation, or, at least, to
changes in the condition of the valvular apparatus probably occurring
during intra-uterine life.

Mr. Osborn contributes a paper, entitled Further Remarks on Anaes-
thetics, concerning which his position as chloroformist to the hospital
entitles him to speak. It is an addendum to a former paper published in
the " Reports" for 1880. There is, however, in this paper very little that
is new to us, save an enumeration of the advantages accruing from the
use of the Clover Inhaler, which, according to Mr. Osborn, "has become
now the favourite apparatus for the administration of anaesthetics in several
of the London hospitals." A description of the most approved form of
this apparatus would have added to the value of Mr. Osborn's paper ; all
we are told is that its mechanism is so constructed " that it lies in the
power of the administrator to give first nitrous-oxide gas alone, then a com-
bination of gas and ether, and, finally, ether alone." While the practical
hints about the effects of the different anaesthetics and the methods of

504

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[Oct.

administration are, as we have said, not very new, they lose nothing in
the repetition, for Mr. Osborn is very clear and explicit in his directions.

One of the most interesting papers in the medical series is that by Dr.
Ord, on Some Cases of Paroxysmal Pyrexia simulating Ague. Dr. Ord
gives the notes of four cases in which the pyrexia was to all appearance
not due to malarial poison, and the diagnoses were respectively: (1) Ul-
cerative Endocarditis (confirmed by subsequent autopsy) ; (2) Jaundice
with Obstruction ; (3) Syphilis ; (4) Renal Calculus. In the first case
the " shivering fits" were daily for a fortnight, then every other day, and
then every third day. After admission to the hospital the patient had
daily rigors for five weeks, when he died. There was on admission "a
marked presystolic thrill over the impulse, a systolic murmur at the apex,
conducted into the left axilla ; and a fainter, apparently independent, sys-
tolic murmur over the aortic valve ; the arteries were everywhere much
thickened, and the pulsation of the brachials and radials was clearly
visible." It is noteworthy that, during the whole period of his illness in
the hospital, the liver and spleen remained large, and the spleen was
tender for one week shortly after admission, facts which tended consider-
ably to complicate the diagnosis. But the post-mortem examination
showed that the heart was the main seat of disease, the following lesions
being present : —

" (1) Pericardial effusion (15 oz.), with no deposit of lymph in heart or peri-
cardium. (2) Dilatation of both ventricles with hypertrophy of the left. (3)
The posterior set of chorda? tendinece of the mitral valve were ruptured, their
ends clubbed, and covered by dark clot. The endocardium showed a white tract
where the free ends would have played against it. The rest of the valve was
natural. There was no effusion in pleura? ; nothing but congestion and oedema
in the lungs. (4) The liver was large, but not obviously diseased. (5) The
spleen was large, much congested, and friable ; there was an old infarct of con-
siderable size near its lower border. (G) The kidneys were large and pale ;
on section being good specimens of the large white kidney of chronic Bright' s
disease."

Such were the lesions presented by this most interesting case ; interest-
ing because the diagnosis on the admission of the patient to the hospital
seemed to lie between ague, suppurative phlebitis (for he had complained
of pain in the left calf, which was swollen and tender), pyaemia, and ulcer-
ative endocarditis, and it was not until he had been under treatment for
some days that the diagnosis was finally refined down to ulcerative endo-
carditis. Dr. Ord refers the pyrexia to the " state of the mitral valve
setting up from time to time excitement in the heart, and through the
heart in the nervous system."

In the second case cited by Dr. Ord the regular period of intermission
was eight days, but the diagnosis wTas clear from the first, as jaundice was
markedly present, and the symptoms pointed " to the existence of gall-
stones, probably impacted, either sticking in the vesical duct or not com-
pletely blocking the common duct; with this there was abundant evidence
of gastro-duodenal irritation."

In the third case the diagnosis was obscure, but there was a specific
history, and the pyrexia speedily disappeared after the exhibition of the
iodide of potassium. In the fourth case the diagnosis was " ague," but
upon the passage of a " stone" the size of a bean from the bladder, the fever
abated, and there has been no return for six months.

The cases are all exceedingly interesting and instructive, as are the re-
marks upon them. Dr. Ord closes his paper by saying : " Two years ago

1883.]

Saint Thomas's Hospital Reports.

505

I witnessed the case of a distinguished Indian officer who had' intermitting
pyrexia, first attributed to malaria, next to hepatic abscess, and at last
proved to be attributable to neither of them, but simply to impacted biliary
calculus."

Mr. Stone contributes his notes of A Case of Triccelian Heart with In-
sufficiency of the Ventricular Septum, and the following synopsis of the
physical signs and post-mortem appearances will be interesting : —

" There was a distinct systolic thrill over the cardiac region, most marked at a
part half way between the left mamma and the sternum, and conveyed upwards
in a diagonal line from the midsternal point toward the outer extremity of the left
clavicle. This was accompanied by a loud rough sound, also systolic in rhythm,
most accentuated at the point covering anatomically the origin of the pulmonary
artery. It was not loud at the apex of the heart ; was almost lost to the right of
the sternum, but was audible over the upper part of the scapula posteriorly, and
less distinctly lower down. The heart was somewhat enlarged toward the left
side." The autopsy showed a ."heart not excessively enlarged, the vessels
springing from it quite normal. Ductus arteriosus not pervious. Water injected
into the left ventricle through the aorta came out freely through the pulmonary
artery. On inserting the finger through the pulmonary valves it met with an ob-
struction about an inch and a half beyond them. The auricles were normal as
regards capacity and thickness of walls. They communicated by a slit-like fissure
at the anterior edge of the septum, such as is not uncommon without producing
any pathological effect. The walls of the right ventricle were hypertrophied to
exactly an equal thickness with those of the left. The cavity of the ventricle was
divided into two chambers, one much smaller than the other, and almost com-
pletely shut off from it by a firm fleshy partition. These two were in communi-
cation through a small circular aperture with cartilaginous margins, studded with
vegetations the size of millet seeds, and about a quarter of an inch in diameter.
The small oval chamber was an inch and a half long, situated between the gene-
ral ventricular cavity and the pulmonary valves. These were quite healthy.
The septum between the ventricles was perforated by a large semilunar orifice in
its upper and undefended space."

Although there was no symptom of cerebral involvement, the brain was
found to be considerably diseased, purulent inflammatory deposits extend-
ing over the pons and inter-pyramidal spaces, and an old abscess being
found in the lateral surface of the right occipital lobe. The whole history
is especially interesting, when taken in connection with the cases reported
by Dr. Peacock, and already alluded to.

Mr. Stone and Mr. Kilner contribute two papers, one on The Use of the
Continued Current in Diabetes, and containing the reports of two cases,
the other on Measurement of the Medical Application of Electricity.

Dr. Taylor presents the Analysis of, and Remarks on, Thirty -one
Cases of Enteric Fever, a paper which gives all the data connected with
the cases treated in the Hospital during 1880-81. The prevalence of the
fever during November is noted, and also a considerable diminution of
cases during the succeeding four months. In 16.1 per cent, of the cases,
the rash did not appear at all during their stay in the Hospital, whilst in
one case " there appeared at the end of the twelfth week an eruption re-
sembling the tache bleuatreof the French authors, with the exception that
it was elevated above the surrounding skin." This was in a prolonged,
double-relapse case. With regard to the temperature, the writer says : —

': In ten cases only (almost one-third), of which two were fatal, did the ther-
mometer register 105° Fahr., and in only three of these did the fever rise above
this point. The highest recorded temperature was 105.6°, which occurred on
the seventeenth day of the disease. The patient recovered. A highest tempe-
rature of 104° and below 105° was frequent, namely in 13 cases, or nearly a half,

506

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[Oct.

with. one death ; whilst temperatures between 102° and 104° included 8 cases,
or over a fourth. There was no highest evening temperature below 102°.
. . On the other hand, very low morning temperatures were frequent, for we find
one with a record of 94°, five with 95°, and sixteen with ~96°, or, in other words,
21 cases whose lowest morning temperatures were between 94° and 96°. Only
one of these was fatal, a boy, aged twelve years, in whom the temperature fell
suddenly from 102.4° to 96.8° at the date of perforation of the bowel."

Diarrhoea occurred in twenty-eight cases, but in eleven of these consti-
pation had also existed at one or another period of their illness. The
tongue was dry in eight cases, dry and brown in nine, and tremulous in
four. Fissuring was noted in four cases. Albumen was detected in the
urine of eight cases, but in six at least it was only temporary. Marked
delirium occurred in eleven cases, in five of which "the greatest intensity
of delirium or its very onset exactly corresponded in date with that of
highest temperatures, and in three others the events were only two days
apart. ... In all cases in which delirium was severe the thermo-
meter registered 105° or upwards." As regards the treatment for these
high temperatures " quinine has been given with only partial success. It
has undoubtedly controlled hyperpyrexia, but only very temporarily, and
then only when given in such doses as produced effects which may be
called toxic." Graduated baths were only administered in tw© cases, but
with very marked effect on the temperatures.

The paper closes with an abstract of the cases of relapse, and may be
regarded as a very valuable contribution to the literature of the subject.

Dr. Harley's paper on Fecal Retention, especially as it affects the
Ccecum, treats of a disease as common as it is slighted by most medical
men — chronic constipation. He starts out with the old-fashioned asser-
tions that " constipation is often the forerunner of enteric fever, and so far
may be regarded as a factor of that disease. . . . Constipation is oc-
casionally the sole cause of enteric fever." This is not exactly orthodox
according to our present lights, but, however that may be, the eight cases
which are cited are full of interest to the practitioner who has to fight
numberless cases of this same sort in his general practice. Case I. was
one of simple idiopathic constipation which had a fatal termination from
a persistent neglect of the demands of nature. Case II. was a passive
variety of the same condition, which readily yielded to appropriate treat-
ment. Case III. was one of fecal accumulations in the caecum inducing
some of the symptoms of enteric fever. Case IV. was one of fatal consti-
pation, without prominent symptoms, the patient being brought to the
Hospital almost in articulo mortis, and the post-mortem examination re-
vealing nothing of the nature of obstructive disease. Case V. was one of
gradual constipation followed by the sudden appearance of symptoms of
obstruction in the caecum, but which yielded to appropriate treatment.
Case VI. Constipation, acute pain in the right iliac region, vomiting after
a hearty meal of whelks; fecal tumour of the caecum, convalescence after
twelve days — a case whose title sufficiently explains it. Case VII. Fecal
constipation, retention of the fecal matter in the caecum, fever, etc.
Case VIII. Constipation, followed by fever and stercoraceous vomiting,
perforation of the stomach and caecum. The history of these cases is very
interesting, and will fully repay careful study.

Finally, Dr. Bristowe gives us an important paper on Hydatid Tu-
mours of the Abdomen and Tumours simulating them : with the history
of three cases, one of hydatid tumours in abdomen, associated with preg-
nancy ; hydatid thrill in small hard tumour only ; one of abdominal can-

1883.]

Saint Thomas's Hospital Reports.

507

cerous and hydatid tumours ; and one of parovarian cyst simulating an hy-
datid tumour. The first case is especially interesting. The woman stated
that she was three or four months pregnant, and "presented five obvious
abdominal tumours, of which three were large, rounded, and elastic, and
fluctuated more or less distinctly; and two were small, hard, and judging
from palpation solid. . . . Two of the large cysts were successively
punched, and from each of them was withdrawn the fluid characteristic of
living hydatid cysts, in one instance hooklets of echinococcis being dis-
covered. The third cyst was also reserved for puncture, but the suspi-
cion of pregnancy made a close examination necessary, and the stethoscope
developed the foetal heart-sounds.

The Report ends with the usual statistical tables for both 1880 and
1881. R. P.R.

At the present time, when medical journals bring so promptly to every
reader the latest facts and theories, and when they preserve so well what-
ever is worth recording, it seems a pity to bury in a volume of very
limited circulation a paper which deserves to be widely read. Yet this
has been the fate of many of those which from time to time have appeared
in the large and valuable reports of certain English hospitals. It is true
that these reports go out to a number of medical journals, and reviewers
pick out and call attention to what is best in them. But, notwithstand-
ing this, it is a sort of burial that a paper undergoes, which is lodged in
one of these volumes. Sometimes, however, this is not so great a misfor-
tune to the world as it is to the author — then the loss of one proves to be
another's gain.

The volume before us suggests and exemplifies these reflections. When
Mr. Nettleship, for example, writes such a paper as here appears under
the title Cases of Orbital Cellulitis presenting unusual Features, it seems
a good saving of the reader's time that he should not be tempted by the
writer's name to linger over what is so loose a commentary on such ques-
tionable cases. At the same time he will avoid the bad example of a
teacher who, while treating eye diseases, records that a patient " says his
water is very thick," and never examines that water to see why it is
thick.

On the other hand, his report of eight Cases of Injury to the Optic
Nerve, and such an interesting case as that of Spondylolysthesis simply
recorded by Robert Cory, M.D., deserve more publicity than they get
here : the former because of its instructiveness, the latter on account of
the rarity of the condition described. The same may be said of the Con-
tribution to Pathology of Double Optic Neuritis by Walter Edmunds,
M.D., which gives a very brief account — illustrated by a plate — of the
gross and microscopical lesions found in the case of a girl, 8 years old,
who was killed by being run over by a horse and cart, receiving, among
other injuries, a fracture of the base of the skull. Though she died
within twenty-four hours of the accident, the optic nerves were red and
swollen just behind the orbit, and showed under the microscope early
inflammatory manifestation between the two sheaths, and somewhat within
the inner one. This case suggests some questions, not answered in the
paper, which seem to us to be well worthy of the attention of neuropatho-
logists.

Henry Gervis, M.D., writes On Topical Applications to the Cervix
Uteri during Pregnancy, and urges the value of such a proceeding in

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[Oct.

cases of threatened abortion due to endometritis, of the nausea of preg-
nancy, of pruritus, and of general uterine uneasiness.

Mr. H. G. Armstrong gives an account of a remarkable result of
Nerve- stretching in a Case of Spinal Meningitis with Ataxic Symptoms
due to Injury. The patient, a man 40 years old, had a fall astride of a
piece of timber. After lying by for a week he resumed work and had
attacks of pain in the sciatic regions — whatever this may mean — and teta-
nic spasms, intermittent but increasing in severity and frequency. After
two years he gave up work, and for three years before the operation grew
worse, having had to spend the last year almost altogether, and the last
four months altogether, in bed. At the time of operation he had " severe
lightning pains confined principally to the legs and lower parts of the

body, though they are occasionally felt in the upper extremities

The lancinating pains and tetanic spasms in the lower limbs can always
be produced by pressure on the skin over the coccyx. Does not attempt
to leave his bed, as on trying to walk he falls down." His muscular
action in his legs was violent and ill-coordinated, patella reflex absent ;
he had complete anaesthesia of both legs below the groin and absence of
sexual power but not of desire. Muscular electro-excitability was only
partially lost. Such being the condition of the patient, Mr. Armstrong
cut down upon the left sciatic nerve below its exit from the sciatic fora-
men and stretched it violently. The operation was painless, though done
without the use of any anaesthetic. In four days the patient's pains were
" very slight," his tactile sensibility was returning in both feet. In ele-
ven days this was established over the whole of both lower extremities.
In sixteen days his legs were under full and steady control of his will.
In twenty-nine days he could walk with " very slight assistance."
Within two months he could walk out regularly, and soon took a walk of
seven miles before breakfast. His sexual power was also restored. After
six months he had some return of his intermittent pains, though they were
much less severe than formerly, and in walking he exhibited the charac-
teristic ataxic gait.

Jottings from the Surgical Out-patient Room, by H. H. Clutton,
M.B.F.R.C.S., Assistant Surgeon to the Hospital, is a very interesting
paper, giving an account of several cases. One was a Fracture of the Cla-
vicle by Muscular Action, which came under the author's observation six
months after its occurrence, and which had healed without surgical assist-
ance. Another case was a Large Vascular Growth in the Neck of a
baby 7 months old. It involved the floor of the mouth, dated from the
child's birth, increased rapidly a few months after. It wras brought for
six weeks to the hospital and then died at home. No autopsy was ob-
tained. It is noteworthy and unfortunate that nothing is said as to the
treatment, and its effect, while the baby was under the author's care.

Three Cases of Ncevi of the Face treated by Electrolysis are given.
They illustrate the advantages of this method in nsevi inaccessible to ope-
ration.

A Congenital Hydrocele of the Neck over the sterno-cleido-mastoid
muscle, in a child 2 years old, was treated by tapping and injection of tr.
iodini and water, in equal parts. After an interval of about two weeks
this was repeated, and at the end of three months all that was left was a
solid lump, about as big as a walnut, below the angle of the jaw.

The jottings close with an interesting account of a case of Multiple
Fatty Tumours in a man 44 years old. The author makes a point of

1883.]

Saint Thomas's Hospital Reports.

509

their symmetrical distribution, and believes that such a distribution is so
common that it may be regarded as indicating a law.

This paper, aside from its instrinsic value, is commendable as a utiliza-
tion of a sort of material which is too often wasted in large hospitals. The
more striking experiences of the wards are no more valuable to men in
general practice, and yet how rarely does one meet with reports from out-
patient departments.

The most curious surgical paper in the volume of reports is that by
Mr. Bernard Pitts, Resident Assistant Surgeon, On Six Cases of
Abdominal Surgery.

Case I. was a woman forty-two years old, who had suffered with constipa-
tion for several months ; nothing passed per anum for two weeks. There
were present all the signs of intestinal obstruction. A central abdominal
incision was made under spray, the hand introduced, and an annular stric-
ture found at the junction of the sigmoid flexure with the rectum. An
incision an inch long was now made "in the left groin," the sigmoid
flexure was drawn into it and secured by silk sutures, the abdominal
cavity was cleansed, the central wound closed, and both wounds dressed
antiseptically. About fourteen hours afterward the dressing was cut away
from the wound in the groin, the cut margin of the central dressing sealed
by strapping dipped in carbolic lotion, and the bowel incised. Gas and
eight ounces of dark fluid evacuation escaped, and feces continued to flow
slowly for the next six hours. The patient made an uninterrupted re-
covery. Six months later she passed a "good deal" of her feces the
natural way — the artificial anus being about the size of one's little finger.

The second case was one where a reducible left inguinal hernia, in a
man forty -five years old, had become strangulated and reduced without the
patient's knowledge. An exploratory abdominal incision was made and
a knuckle of bowel that had been constricted found. As it looked recover-
able, nothing else was done, but the abdomen was closed at once. In the
evening the patient became delirious, and died.

The third case was one of strangulated right inguinal hernia, in a man
also forty-five years old. He entered the hospital about six hours after his
hernia came down, and he failed to reduce it. The next morning it was
reduced by the surgeon. The bowel went back in the usual way, but
"without a definite gurgle" After a short period of apparent ameliora-
tion symptoms of obstruction became pronounced, and Mr. Pitts cut down
on and explored the sac, continuing his incision upwards and outwards on
the abdominal wall for about three inches. Here a part of the large intes-
tine was found to be ashy-gray and soft for about two inches of its length.
This was brought down and fastened to the edges of the wound. An arti-
ficial anus formed ; but the patient died ten days later of pneumonia and
exhaustion.

The fourth case was one of congenital imperforate rectum, in an infant
two days old. An attempt to open it through the perineum failed, and
then the author opened the left groin and brought up the sigmoid flexure,
fastened it to the edges of the wound, and opened it. All went well for a
few days, but then the child did badly, and died at the end of sixteen
days of surgical kidneys. At the post mortem the rectum was found to
end in a small opening on the floor of the urethra, just in front of the
veru-montanum.

The fifth case was one of a child four and a half years old, suffering with
acute intussusception low down in the colon. Inflation with air was

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[Oct.

attempted. At first it did not succeed ; then the child was suspended by
the heels, and by manipulation partial reduction effected with a finger in
the rectum and the other hand drawing upon the tumour through the wall
of the abdomen ; then inflation with air finished the reduction very
readily.

The sixth case was a man, forty-five years old, with a large irreducible
and apparently strangulated femoral hernia. The tumour was larger than
a man's head. The sac was opened and found to contain about a pint of
serum besides the crecum and part of the ascending colon, together with
five or six feet of small intestine and a large quantity of omentum, ad-
herent to the sac. A considerable quantity of omentum was removed, the
intestines returned, and the sac dissected out. The part of the sac re-
moved measured twenty-six inches in circumference. A radical cure was
now attempted by suturing the edges of the sac with catgut. Recovery
followed.

A note is added of a case of a woman with a similar hernia, the author had
a year and a half before, when an operation was delayed for several days
because gurgling could be felt, the result being the death of the patient.
On these facts he bases a plea for early operation, which plea is well sup-
ported by the cases cited.

Finally, the volume contains an excellent paper by Mr. William
Anderson, On Congenital Hypertrophy, which, founded upon one case
appearing in the hospital, gives a summary of the present state of know-
ledge in regard to this rare and curious disorder.

An examination of the statistical tables of this volume reveals some
interesting and instructive facts. The first is the large number of cases
treated in St. Thomas's Hospital. There were, in 1880, 3951, of which
2273 were surgical. In 1881, there were 4174, of which 2329 were
surgical.

If we look at the tables of disease, we find the sometimes contested
statement of Mr. Allingham, that more cases of fistula in ano are met
with than of hemorrhoids, borne out; for, in 1880 and 1881, there were
here forty-two of the former and only twenty-five of the latter.

Intussusception shows 2 cases, both occurring in 1880 ; both were aged
three months; both were operated by abdominal section, and both died.

Genu valgum was treated twenty-eight times, sixteen times by subcu-
taneous osteotomy.

Tracheotomy was done, in 1880, eight times: two for tetanus, two for
diphtheria, one for hemorrhage into glottis, one for erysipelatous oedema
of the neck, one for dyspnoea from pressure of an aneurism of the aorta —
seven ended fatally. (A search through the tables has not been rewarded
by finding in which case recovery followed.) In 1881, it was done five
times : once for a foreign body, once for diphtheria, once for punctured
wounds of the trachea, once for a scald — all of these recovering, — and
once in connection with removal of the thyroid gland for bronchocele,
where death followed.

The tables of hernia show for strangulated inguinal hernia, in 1880,
23 cases, 8 of which were operated upon, five of the latter dying ; no case
unoperated died. In 1881, there were 27 cases, 15 operated upon, of
which eight died — again no case unoperated died. Of strangulated femoral
hernia there were, in 1880, 19 cases, 13 operated upon, of which two died
— no case unoperated died. In 1881, there were 14 cases, 9 operated, five
of which died — again no unoperated case died. Of strangulated umbili-

1883.]

Saint Thomas's Hospital Reports.

511

cal hernia there were, in 1880, 8 cases, of which 4 were operated, all of
which died — one unoperated case put in this table died of exhaustion after
nineteen clays, without peritonitis and without evidence of strangulation ;
3 cases treated only with ice recovered. (In regard to these figures, we
would remark, that there seems to be in the report some confusion of the
condition of incarceration with that of strangulation.)

In 1880 abdominal section is said to have been done in 4 cases, two
already mentioned in speaking of intussusception, one for stricture of the
rectum, and one for "etc." (In regard to this the tables are conflicting
and contradictory.) In 1881 there were 2 cases of abdominal section
proper, both for intestinal obstruction, one after colotomy, and both ended
fatally. Two cases are put under this head in the table of operations for
1881 , which were only extensions of the incision in operations for inguinal
hernia ; and there were three of them — not two — all ending fatally.

In 1880 there were 6 operations of lateral lithotomy (left?), one of
which ended fatally, and 3 of lithotrity, in one of which there were four
stones, 1 being crushed and 3 "removed by Bigelow's apparatus." In
1881 there were 2 operations of lateral lithotomy, one fatal, and one where
a calculus was removed by dilating the female urethra. There was also
an operation twice set down as a " nephrotomy," which consisted of re-
moving, by incision, a stone lodged in a sinus in the loin " some distance
from kidney."

This is a slim showing for two years in the hospital of Cheselden.

Of excisions of the hip there were, in 1880, 17 with but 3 deaths, in
one of which there was nephritis, in one hemorrhage, and in one collapse.
In 1881 there were 14 with 3 deaths, in one of which the wound was
healed, in one almost, and in all evidence of tuberculous disease in lungs
or brain, or both.

Of ovariotomies there were, in 1880, 15 with 3 deaths; in 1881, 17
with 4 deaths.

In 1880 there was one ablation of the entire uterus above one-and-a-
half inch from the os, with a fibroid tumour, followed by recovery ; and
one case of fibroid tumour, where "a portion" of the uterus was removed,
with the Fallopian tubes, death following in five days from hemorrhage into
the abdominal cavity. In 1881 a large intra-mural fibroid was removed
with the body of the uterus and ovaries, and the patient died in three days,
never recovering from the shock. Another tumour was removed with both
ovaries and the upper part of the uterus. The patient died in sixteen
hours; the peritoneal cavity, at the autopsy, was found to contain about a
pint of fluid blood.

In 1880 the femoral artery was twice ligated in Scarpa's triangle for
popliteal aneurism, once after digital compression and forced flexion had
failed ; both cases were cured. Once the common carotid artery was
ligated — for what our examination of the tables has not discovered. In
1881 the subclavian artery was ligated for aneurism of the subclavian (?),
which was improved ; once the external iliac artery was ligated for aneu-
rism in the left groin, which resulted in "slow consolidation;" once the
common carotid artery was tied — for what we cannot discover — the opera-
tion being "followed by suppuration of vitreous on same side, secondary
hemorrhage, and ligature of lingual artery in the wound." This patient
was still in the hospital when the report was made up.

In 1880 there was a case of "branchial fistula" in a young man twenty
years old, which was cured. It is a great pity that this is all that is stated

512

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[Oct.

about a case which might have proved very interesting in its details. In
1881 there was one case of perforating ulcer of the foot with diabetes,
which ended fatally.

In 1880 there were 5 cases of tetanus treated, in two of which chloro-
form was given and tracheotomy done ; both died. Chloral was used
successfully in two cases and unsuccessfully in one. In 1881 there were
2 cases of tetanus ; both died ; in one morphia and chloroform were used,
and in one bromide of potassium, nutrient enemata, and laryngotomy ;
fifteen minutes after which death occurred.

In 1880 there were 95 cases of erysipelas with 7 deaths; and in 1881
there were 104 with 12 deaths. One of the latter was developed in the
hospital, in a man, after an operation for strangulated femoral hernia
carried out under antiseptic precautions.

In 1880 there were no cases of pynemia; in 1881 there were 5, all fatal.

From this abstract it may be seen how interesting and instructive are
these statistics, and how suggestive they are in regard to certain surgical
disorders and their treatment. They are a very valuable contribution to
the literature of surgery. They are not faultless, however. Perhaps this
would be too much to expect. But, after making reasonable allowance for
clinical errors and for the difficulty a registrar may have in reconciling the
accounts received from dressers and internes, there remain here some
defects, which we think might be corrected without too much trouble, and
the correction of which would add to the attractiveness and value of these
reports. It may be regarded as a matter of taste entirely, but we do not
fancy the expressions : "soft sore" and " smash of foot;" we find " erup-
tion on hand" too vague; "lamboidal" is probably a misprint, but " Collis"
(for Colles's) occurs too often to be so explained. We find the punctua-
tion so defective, in a number of cases, as to leave us quite in the dark
as to the real significance of the figures and remarks, and occasionally an
"etc." upsets our calculations entirely. We find, by investigation, certain
cases duplicated without sufficient indication of the fact. In other cases
we find that the tables do not agree, and when we search for details of one
statement, we are met with only apparent contradictions of it. We find
no distinction of hemorrhoids as to whether they were internal or external.
And, finally, we are a little surprised to meet among the " Trivial Cases"
one of chronic otitis and meningitis, which resulted in the death of the
patient.

So much by way of criticism, which we offer not without a pretty good
knowledge of the great difficulty of keeping correctly and reporting satis-
factorily the surgical records of a large hospital. C. W. D.

Art. XVII Guy's Hospital Reports. Edited by H. G. Howse, M.S.,

and Frederick Taylor, M.D. Yol. XLL, pp. 515. London : J. & A.
Churchill, 1883.

The leading article in this bulky volume is a biographical notice of
Joseph Towne, modeller to Guy's Hospital for fifty-three years, by Thomas
Bryant, Senior Surgeon to the Hospital, from which it appears that this
skilful artist became attached to the institution in 1826 when a lad of only

1883.]

Guy's Hospital Reports.

513

seventeen years old. His first work was, curiously enough, the modelling
of a human skeleton, accomplished surreptitiously at night for fear of his
father's displeasure, and by the advice of a friend he brought it from his
native country village to London, and exhibited it to Mr., afterwards Sir
Astley Cooper. That great man at once recognized in the rustic youth a
true genius for such work, and immediately secured his services for Guy's
Hospital, the museum of which seems to have been wonderfully enriched
by his productions. Among the numerous examples of felicitous diction
with which Mr. Bryant has adorned this memoir, it seems strange to find
the following on p. 12 : " Mr. Towne was married on September 20,
1832 .... and left several children. He left also some models for
disposal, the best of which were purchased for the museum of Guy's," etc.

A case of Phosphorus Poisoning which ended in Recovery under the
Administration of Oil of Turpentine* reported by C. Hilton Fagge,
M.D., forms the second paper, and affords some confirmation of the value
of this oil as a remedy as first suggested by Andant, whose detailed essay
may be found in the Annates d' Hygiene for 1873. Although all the cases
of acute phosphorus poisoning previously treated in the hospital had proved
fatal, Dr. Fagge admits that the favourable issue in this instance should
not be accepted as proof that turpentine is an effectual antidote, since
several examples of recovery after hepatic enlargement, jaundice, and
other severe symptoms appeared, are on record.

Dr. W. Hale White next reports a curious Case of Symmetrical
So ftening of the Corpora Striata, followed by bilateral descending degene-
ration with secondary anterior poliomyelitis. This patient's malady seems
to have quite baffled the diagnostic acumen of its reporter during life, and
the only record of internal treatment is that of the administration of large
doses of iodide of potassium, from which we may infer that the idea of
some specific neoplasm to be absorbed rather than that of a degeneration
to be arrested was entertained. The literature of the subject appears to
to have been pretty thoroughly studied.

In a short essay upon Exophthalmic Goitre ivith Mental Disorders,
Dr. George H. Savage relates the histories of three cases of Grave's
disease complicated with insanity, and of some other instances where
insanity was accompanied with one or more symptoms of exophthalmic
goitre. Savage asserts that but few cases of fully developed insanity with
this variety of goitre are on record, although his experience shows that
Grave's disease is more common among the insane than among the sane,
and that in the former case the mental symptoms are apt to be of a
melancholic order. Under these circumstances there seems to be some-
thing special in the type of insanity to which, however, Savage is unable
to give any distinctive characteristics in writing, except that the melancholia
is of a suspicious kind, followed by mania of a very violent nature, with a
tendency to emaciation and death.

The next article is entitled Cases of Empyema in Children treated by
Removal of a Portion of Rib, by W. Arbuthnot Lane, B.S. It is
founded upon five cases, three of which were successful, the other two
proving fatal on the eighth and twenty-second days respectively. Lane
advocates the free use of hypodermic punctures over the surface area of a
supposed pus cavity in the chest, in order to determine its size and depth ;
and great care in securing an aperture at the lowest point in order that the
whole of the pus may be promptly drained off, and the employment of a
large, soft rubber drainage tube for the purpose of securing a continued
No. CLXXII Oct. 1883. 33

514

Reviews.

[Oct.

free discharge. His experience with the method of preserving the peri-
osteum has been quite favourable, no excessive formation of osseous
material having obstructed the artificial outlet in any of these instances.

Drs. R. E. Carringtox, P. Horrocks, and W. H. White give in
the succeeding paper an account of the Abnormalities observed in the
Dissecting Room of Guy's Hospital, during the Sessions 1880-81 and
1881-82, these being detected in the pursuit of practical anatomy upon
181 subjects. Among numerous minor abnormalities of the muscular
system the most important seems to be a muscular slip about three inches
long over the right popliteal space, without osseous attachments, which may
have been either a slip from one of the hamstrings or a third head to the
gastrocnemius. A curious arterial anomaly was the giving off of the
innominate artery on the left side of the trachea, which it crossed about
an inch above the sternum, of course, in a situation where it might render
the operation of tracheotomy immediately fatal. Numerous less important
variations in sundry parts of the arterial, venous, and nervous systems
were noticed, and in one instance a kidney (Fig. 13) was found in an
abnormal position, lying diagonally across the left sacro-iliac synchondrosis
and partly projecting into the cavity of the pelvis.

Two Cases of Pulsatile Tumour at the Boot of the JS7eck are described
by C. H. Golding-Bird, and F. A. Mahomed, M.D. One of these
was an aneurism accompanied by peculiar symptoms, and the other was
a post-sternal abscess which simulated aneurism. The great interest of
this paper lies in the fact that by the aid of the Sphygmograph Dr.
Mahomed arrived at a correct diagnosis in each instance on a first exami-
nation, and maintained it throughout, in spite of the conflicting opinions
of several eminent medical men who examined the patients at different
periods. Dr. Golding-Bird deserves great credit for the honest frankness
with which he records the error into which he was led, notwithstanding his
careful and faithful study of the history, signs, and symptoms in the latter
of these obscure cases.

The first long article in this volume is a treatise on The Surgical
Affections of the Tongue, by Thomas Bryant, written with the purpose
of doing something towards filling the gap (as the tongue always does)
left by scanty notice of diseases involving this important organ in previous
numbers of the Hospital Reports. This paper is illustrated with two
superb coloured lithographic plates, and also by three pages of lithographs
representing microscopic appearances of some of the morbid growths
described. These latter suggest that the drawings have been made under
lenses sadly wanting in definition, and leave much to be desired in the
wray of clearness.

Among congenital affections of the tongue hypertrophy or macro-glossia
is represented by two instructive cases, the first of which in a boy was
repeatedly relieved by mercurials, and the other in a young man was
cured(?), although of twelve years' standing, in a week by ten-grain doses
of iodide of potassium. Several examples of naevi and other congenital
tumours of the tongue are given ; moat of these were operated upon, but
in one remarkable instance which was not interfered with, cystic degene-
ration took place resulting in a great amelioration of the condition of the
child by the time she reached her twelfth year.

After discussing inflammation and simple ulcer of the tongue Bryant
considers at length syphilitic and tubercular ulcerations, cancer of the tongue
(in which he strongly advocates operation, and records one instance where

1883.]

Guy's Hospital Reports.

515

the disease did not return until fifteen years later), and concludes his valua-
ble monograph with notice of that peculiar affection, ichthyosis of the lin-
gual organ, which he has seen benefited by arsenic when not too far
advanced, but believes in its confirmed stage must be treated by excision.

Mr. Samuel Wilks contributes a very interesting paper On Hemian-
esthesia, in which he records several curious cases of real or supposed
brain lesions associated with this condition, including one of a French-
man who was for a time a patient in Guy's Hospital, and after being
discharged much improved suffered a relapse, from which he was " miracu-
lously cured" by immersion into the waters of the holy well of Lourdes,
in conjunction with the devout prayers of the Archbishop of Cambrai
and numerous followers. Wilks also relates some experiments to test the
value of the new system of " metallotherapie," the result of which will by
no means satisfy its ardent Gallic advocates.

In a brief essay upon Saturnine Lunacy, Dr. James F. Goodhart
recounts the histories of four patients suffering from this malady, and
admirably indicates the importance, from a therapeutic point of view, of
diagnosing this little known affection from delirium tremens and from
general paralysis, diseases which, at different stages of its course, it may
very closely resemble.

In the next article upon Acute Gonorrheal Rheumatism, Mr. J. N. C.
Davies-Colley takes occasion to correct the views he expressed some
four years ago in the Obstetrical Journal, and informs us that he no longer
considers the variety of the disease then described peculiar to women, as
he has since observed it in three individuals of the male sex. This form
Davies-Colley believes is characterized by its appearing during the acute
stage of gonorrhoea, attacking at the outset several joints, and afterwards
centring in one, most frequently the elbow-joint, and by its affecting
especially the fibrous tissues of the articulation, and only secondarily the
synovial membrane and cartilages. The affection is not amenable to ordi-
nary anti-rheumatic remedies, the best treatment being to cure the dis-
charge, keep the part perfectly still, apply uniform pressure during the
acute stage, and when that terminates resort to passive motion.

Mr. W. H. A. Jacobs on furnishes a thoughtful paper On the Minute
Anatomy and Origin of the Enchondromata of the Salivary Glands, in
which, after a concise account of the position, external characters, structure,
and treatment of these unsightly neoplasms, Jacobson advances some inter-
esting arguments partly derived from embryological studies of the jaw and
ear, etc., in favour of Cohnheim's ingenious theory that the main source of
origin for tumours consists in certain relics of foetal tissues, which, owing
either to their being superfluous or to their development being arrested, have
never reached maturity, but have remained quiescent in the midst of better
developed structures. It must be remembered, however, that plausible as
this hypothesis is, it remains as yet entirely without proof, which will from
the nature of the case always be difficult, if not impossible, to obtain.
The essay is imperfectly illustrated by two lithographic plates, one pur-
porting to represent the microscopic and the other the macroscopic
characters of these formations.

The longest article is furnished by Dr. P. H. Pye-$mith, and is enti-
tled Reports of a Case of Idiopathic Ancemia of Addison, since called
essential, pernicious or progressive anaemia, with a commentary and tables
of selected cases. It forms a valuable contribution to the literature of
this obscure and remarkable malady, but is too extended for abstract in

516

Reviews.

[Oct.

our present notice. Dr. Pye-Smith gives tables of: A, 7 cases of fatal
and probably idiopathic anaemia, recorded before Addison's description of
the disease in 1855 ; B, 103 selected cases of idiopathic anaemia, followed
by death and autopsy, recorded since 1855 ; and C, 20 cases of recovery
from idiopathic and profound anaemia. In regard to treatment Pye-Smith
states that he has lost all confidence in iron and phosphorus, but has seen
marked benefit follow the administration of arsenic, and temporary improve-
ment result from transfusion of blood. This paper should be studied by
every medical practitioner having an obscure or doubtful case of anaemia
under his care.

Dr. Thomas Stevenson's case of Poisoning by Aconitine is the cele-
brated one of G. H. Lamson, an alleged medical graduate of one of our
American colleges, who was convicted and executed for the murder of his
brother-in-law, Percy John, in 1881. The rarity of fatal poisoning by
aconitine, the combined ingenuity and stupidity of the criminal, and the
novelty of some of the points raised in the examination and trial, will
doubtless render this case, as Dr. Stevenson anticipates, the leading one
on this subject, in forensic medicine, for many years to come. The fatal
dose of two grains of Morson's (?) aconitine was probably administered
in one of the gelatine capsules so commonly used here in America for the
purpose of avoiding the taste of nauseous medicines, and death resulted,
after great suffering, in about four hours. The tests relied upon were the
effect upon the tongue of the analyst, the reaction with phospho-molybdic
acid, and the physiological tests upon mice, which were found to be more
satisfactory than frogs for this purpose. One-thirteenth of a grain of the
alkaloidal extract obtained from one and a half fluidounces of the urine,
in this instance, was so skilfully manipulated by Dr. Stevenson that after
it had been tasted by three persons, and tested specifically for morphia and
strychnia, the residue sufficed to kill two mice when injected beneath the
skin of the back, with all the symptoms of aconite poisoning.

Dr. C. H. Golding-Bird's paper, Laboratory Notes on the Working
of the Histological Glass, contains much of interest to instructors in this
important department. His answer to the question, "What is the easiest
way of getting sections of tissues for the microscope?" which is commonly
put to him, not only by present, but by past pupils, appears to be briefly:
Harden the tissue in one-quarter per cent, aqueous chromic acid solu-
tion ; then soak in gum mucilage, and cut sections by the aid of the freezing
microtome. The best form of this instrument is, he asserts, that of Wil-
liams, where the freezing mixture is ice and salt ; but although " the best,"
this apparatus has been superseded by Grove's modification, in which
ether is employed. The staining materials used are eosine, picro-eosine,
and logwood solution. Eosine, he declares, "is no good alone," but in
conjunction with haematoxylon answers well. The course includes, we
are pleased to observe, lessons upon development, as illustrated in the
embryo chick, to furnish specimens of which, eggs are incubated as recom-
mended by Balfour and Foster.

Gases of Paralysis of the Abductors of the Vocal Cords, by Dr. Fred-
erick Taylor, comprise interesting reports of six examples of this
affection, coming under Taylor's notice in Guy's Hospital during the last
two or three years, with comments upon their respective peculiarities. Two
of these instances in which recovery took place are of value, as demon-
strating the fact " that dyspnoea and inspiratory stridor, from approxima-
tion of the vocal cords, may occur as a temporary affection, which is not

1883.] Sanitary Report of Surgeon-General of the Navy. 517

spasmodic, and has not for its remote cause an organic lesion, but prob-
ably some condition of nerve-failure, as hysteria or exhaustion."

A long article describing thirteen Cases of Multiple Small Abscesses of
the Liver, by Dr. R. E. Carrington, is apologized for on account of un-
necessary prolixity of detail, because Carrington wished to make the
histories complete, in order that their obscurity from a clinical point of
view might be apparent. From an instructive analysis of these reports
we find that the duration of illness was very variable, running from five
to eighty days ; that wasting of the body was always a prominent symptom ;
that abdominal distension was present in eight out of eleven cases ; that
the liver was enlarged in every instance save one ; vomiting occurred in
half the cases ; rigors were common ; and an irregular febrile movement
almost universal. Carrington states that ten "of the examples were of
infective origin, but no microscopic examination of the smaller foci of in-
flammation to determine the presence of pycemic micrococci in the intra-
lobular vessels appears to have been attempted. We would strongly urge
our author to undertake such an investigation at the first opportunity
which may fall in his way in the future.

An illustrated paper on Pes Valgus Acqui situs ; Pes Pronatus Acquisitus
and Pes Cavus, by Mr. C. H. Goldixg-Bird, without containing much
that is new, does really, as Golding-Bird hopes, tell much that will bear
repetition, both on account of its clinical interest and with respect to treat-
ment. Golding-Bird's results in cases of acquired pes pronatus, from a
simplified modification of BarwelPs apparatus, with an artificial India-
rubber " tendon" to draw up the arch of the foot, appear to have been
eminently satisfactory.

Another essay by Dr. Thomas Stevenson, the industrious lecturer
on medical jurisprudence at Guy's, has for its subject Lead Poisoning,
giving some useful facts in regard to saturnine- water contamination, and
reports the first English case of death from the homicidal administration
of lead acetate, all of which will be perused with advantage by those of
our readers who take an interest in forensic medicine.

The last monograph is by Dr. W. A. Brailey, and treats of that some-
what neglected subject, The Vitreous Body in its Relation to Various
Diseases of the Eye. It gives the results of numerous observations upon
the consistency, size, general appearances, and microscopical characters of
the vitreous as found in excised eyes, and exhibits a praiseworthy effort
to make the best use of opportunities for investigation which compara-
tively few observers enjoy.

Lists of prizemen, members-elect of the Royal College of Physicians
and of Surgeons, appointees, etc., conclude the volume, which testifies to
an amount of faithful and diligent medical work of which its illustrious
staff may well be proud. J. G. R.

Art. XVIII — Sanitary and Statistical Report of the Surg eon- General
of the Navy for the year 1881. 8vo. pp. 684. Government Printing
Office : Washington, D. C, 1883.

The medical corps of the navy, including all grades of the "active
list," consists of 168 officers, each of whom has been carefully examined,

518

Reviews.

[Oct.

before appointment, in reference to his professional, moral, and physical
fitness to discharge the duties of his office. These gentlemen are far
better qualified as general practitioners when admitted into the navy, than
the average of graduates of our medical schools when they begin to prac-
tise. The Surgeon-General begins his report with a statement, substan-
tially, that they ably perform their duties, and that a desire to increase
their own professional efficiency is common among them. For this reason
it is his pleasure to encourage them to cultivate medical science, by
placing within their reach whatever facilities and indulgence he is able to
command. Medical men thus characterized should be accurate observers;
and, therefore, their contributions to medical literature should be entitled
to confidence.

In a general way, the results of their work are the materials of the
Report of the Surgeon-General.

The amount of money estimated to be needed in the Medical Depart-
ment of the Navy for the year ending June 30, 1884, and the condition
of the Naval Hospital fund are stated in detail ; and, next, that 65 cases
from the navy have been treated during the year in the Government
Hospital for the Insane, and that 50 cases remain, including G officers in
the number.

Of the entire force, including 469 remaining from the preceding year,
14,013 cases of disease were treated. Of these, 11,863 recovered ; 1345
were sent to hospitals, 308 discharged from the naval service, 97 died,
and 400 remained under treatment at the end of the year. The average
daily sick-rate was 457.33, and the average duration of treatment of each
case was 11.91 days.

Considered in connection with the fact that all persons in the naval
service are " selected lives," the sick-rate and mortality seem to be large.
After due examination at the date of enlistment, every recruit is pro-
nounced to be in good condition of health, and free from manifest sign of
hereditary or acquired predisposition to disease. Of 6792 adults and
2015 minors examined, 1967 of the former and 783 of the latter were
rejected ; that is, thirty-one per cent, of the examinates were found not
physically qualified for the naval service. The numerous causes assigned
tor rejecting candidates are classified and appropriately detailed in a
tabular form, which covers nearly three pages. Constitutional diseases
are assigned for the rejection of 151, of which 115 were syphilis; diseases
of the eye, 590 ; diseases of the circulatory system, 364 ; of the digestive
system, 456 ; of the genito-urinary system, 142 ; and on account of defec-
tive development, 661. These rejections imply that at least one class of
the working population of the country contains a large percentage of
males who are more or less disqualified by physical defects and diseases
to depend upon their own labour for a livelihood; and that, sooner or later,
they will be objects of public charity.

The force afloat was 9546. The number of cases treated was 9483,
or 993.4 per thousand; of which 8278 recovered; 964, or 100.94 per
thousand, were sent to hospital ; 36, or 3.78 per thousand Avere invalided
from the service ; 28, or 3.03 per thousand died; and 176 were continued
to the next year.

The admissions to treatment in the Prussian [German?], Austrian,
and English navies were respectively 1369.4, 1006.36, and 1172.36 per
thousand; the invaliding 99.2, 38.80, and 31.11 per thousand; and the
death-rate 2.5, 7.60, and 12.57 per thousand.

A comparison of the relative health of our squadrons shows the admis-

1883.]

Sanitary Report of Surgeon-General of the Navy.

519

sion-rate of the North Atlantic to be 16.83 per cent. ; the Asiatic, 23.70
per cent. ; the South Atlantic, 24.81 per cent. ; the Pacific, 25.52 per
cent. ; the European, 27.08 per cent. ; and special service, 35.16 per cent.
The details are given in a table.

The number of cases of each disease of the classification followed is next
given, with a table of details, which occupies ten pages.

Next are presented notes on the influence of age upon morbidity, illus-
trated by a graphic table showing the prevalence of diseases at the different
decennial periods and for all ages between 15 and 55 years. This is fol-
lowed by a table of twenty pages, " showing the number of cases of
disease and injury, the number invalided and dead, in decennial periods,
with rates per thousand of force at those periods."

The mean force, 9546, is grouped in five decennial periods; in the first,
from 15 to 25, are 4191 men; in the second, between 25 and 35, are
3385 men ; in the third, between 35 and 45, are 1398 men ; in the fourth,
between 45 and 55, are 446 ; and in the fifth are 126 men above 55 years
of age.

The death-rate is highest in the fourth decennial period, less in the
third, still less in the second, and least in the first. This death-rate cor-
responds in a general way with the mortuary returns of Philadelphia for
1880.1

Under the head of " Sanitary Investigations," studies of different
organisms found in air-dust, by Passed Assistant-Surgeon T. H. Streets,
follow. The paper is illustrated by two heliotype plates, one of Bacillus
subtilis and one of B. ruber.

The report of a board appointed to examine the proposed site of the
new Naval Observatory, with reference to its salubrity, is given under the
same head. The board carefully examined the topography, buildings,
water supply, drainage, soil, and air. Its report, in which chemical ana-
lyses and microscopic observations are detailed, is illustrated by seven
wood-cuts and four heliotypes, representing Bacteria from water through
which air had been passed : Bacteria from sediment of well-water; Bacillus
subtilis from well-water, and organisms from atomization of ground air.
" After a careful examination of the ' new observatory site,' the board is
of the opinion that it is, from a sanitary point of view, a fortunate selec-
tion ; and that it can become an unhealthy place of residence only in con-
sequence of the neglect of simple sanitary precautions in the future."

The naval force is employed in different regions. Limits are arbitrarily
assigned to them. They are called stations, and each is designated by a
name. Having treated of the entire force, of the force afloat, recruiting,
etc., the Surgeon-General then considers in detail the force employed on
each station, beginning with the " sanitary condition of the North At-
lantic Station." This includes a region which lies between the coast and
the forty-third meridian of west longitude, extending from the equator to
fifty-five degrees north latitude. An outline map of the station is given.

The mean strength of the North Atlantic Station was 5000 for the
year 1881, distributed in 37 vessels, of which 12 were active cruisers, 9
practice and training ships, 5 receiving ships, 3 survey vessels, and 8
iron-clads in ordinary. The admissions of sick were 911.80 per thousand;
discharged recovered, 761.8 per thousand; invalided to hospital, 132.2
per thousand; from the service, 2.6 per thousand; died, 2.6 per thousand.

The sick-rate per thousand in each vessel is given in a table for three

1 Eeport on Meteorology and Epidemics. By Kichard A. Cleemann, M.D. Trans-
actions of the College of Physicians of Philadelphia, third series, vol. vi. 18S3.

520

Reviews.

[Oct.

years, including 1881, showing, by comparison, marked improvement in
the health of this station. The average loss of service per thousand from
the several classes of disease is set forth in the same manner. A table
shows the classes of disease on account of which patients were transferred
to hospitals ; another, arranged in the same manner, the causes of invalid-
ing from the service. A table exhibiting the invaliding in each of the
vessels, with the ratios for the preceding year, is given ; also, one of the
number of deaths, with the classes of disease to which they were ascribed,
and the mortuary rate per thousand.

Next follow a table of the number of the cases per thousand in each
vessel for the years 1879, '80, '81 ; and then a statement of the number
of cases of each disease. The results of 3358 vaccinations are given in a
table which shows the per cent, of successful cases.

The number of cases of each disease of each class is stated, and for
some of the classes of disease a table of the ratios per thousand of cases
occurring in each ship is given for the years 1879, '80, '81, showing the
prevalence of the class.

Under "Naval Hygiene" is given an outline of the sanitary condition
and cruising of each vessel, arranged in succession according to name, in
alphabetical order, beginning with the Alarm and ending with the Yantic.
A graphic chart, showing the presence of parts of carbon binoxide to the
one thousand in the atmosphere of the interior of the ship ; the relative
humidity; the percentage of sick, excluding injuries ; average strength ;
average temperature ; number of days of snow or rain ; number of days on
which the berth deck was washed ; and the ports visited in every month
of the year, is given. Twelve such charts illustrate the hygienic condi-
tion of vessels on the North Atlantic Station.

" Hygiene" is succeeded by " Medical Topography and Sanitary Re-
ports," from Surgeon G. F. Winslow, of the Yandalia, Passed Assistant-
Surgeon H. C. Ecksteine, of the Alliance, and Passed Assistant-Surgeon
H. Aulick, of the Despatch.

Tables, covering 112 pages, in which the wrhole matter is classified and
numerically detailed, closes the report for the North Atlantic Station.

The sanitary condition of the South Atlantic, of the Pacific, of the
European, and of the Asiatic stations; of vessels on special service; of
naval hospitals ; and of naval stations or navy yards, is presented in the
same manner. The volume is closed with an admirable " Report on the
Pharmacopoeias of all Nations," by Surgeon J. M. Flint.

The illustrations consist of five maps to show the limits of the stations,
nineteen graphic charts, six heliotypes, and seven wood-cuts. The tables,
exclusive of those intercalated in the text, occupy 378 pages. The com-
putations requisite to construct these very full and extensive tables, involve
very considerable labour. Whether their results are at present a com-
pensation or not for the work and time they must have cost, it is very
probable that in the future, when like data shall have been gathered and
tabulated for ten or fifteen years more, they may be a source of informa-
tion of much value to the navy, and of much interest to the medical pro-
fession. At this time, however, a study of these great tables is not likely
to be attractive or profitable to medical students who are not employed in
naval or maritime medical service. There can be no doubt, however,
that Surgeon-General Philip S. Wales is entitled to general commendation
for his industrious efforts to secure a faithful and accessible record of the
sanitary statistics of the navy. In this particular he is in advance of his
predecessors in office. The example of his industry and active interest

1883.]

Hammond, Treatise on Insanity.

521

in the progress of medical science should exercise a beneficial influence
on those whose professional work he leads and generally directs. But a
comparison of the number of practitioners, 168, with the number of cases
treated, 14,013, suggests that too few fall to the care of one to hold his
mind closely to the consideration of metlical subjects ; and that for lack of
professional work he may easily drift into collateral science, general lite-
rature, or even into the idle enjoyment of leisure whenever opportunity
offers, just as his innate proclivity, or training, or taste, may invite. How
to guard against such aberrations, and impart to every member of his
corps zeal to labour within the limits of the profession, with little pro-
fessional work to do, seems to be a problem not yet solved. Remembering
the high qualifications claimed, and the opportunities afforded to them in
every part of the world for observation in medicine, in the collateral
sciences, etc., the medical officers of the navy, as a body, have contributed
less to the common stock of our knowledge than could have been perhaps
reasonably anticipated. Comparatively few have attempted todo more than
the faithful and efficient performance of routine duties require, and beyond
this we have no right to insist upon their doing. Yet, it is admitted,
spontaneous, volunteer labours have produced most admirable results, and
won for the labourers enviable reputation. W. S. W. R.

Art. XIX A Treatise on Insanity in its Medical Relations. By

William A. Hammond, M.D., Surgeon-General United States Army
(Retired List) ; Professor of Diseases of the Mind and Nervous
System in the New York Post-Graduate Medical School ; President of
the American Neurological Association, etc. 8vo., 767 pages. New
York : D. Appleton & Co., 1883.

It is a remarkable fact that the authors of the only systematic treatises
on insanity which have yet appeared in this country have not been con-
nected as superintendents with any of our asylums or hospitals for the
insane. These works, three in number are (1) Medical Inquiries and
Observations upon the Diseases of the Mind, by Dr. Benjamin Rush,
published in 1812 ; (2) Dr. Hammond's Treatise on Insanity, the subject
of the present notice; and (3) a work on Insanity; its Classification,
Diagnosis, and Treatment, by Dr. E. C. Spitzka, which has also just
appeared. The late Dr. Isaac Ray, for many years superintendent of a
New England asylum, was the author of three valuable works, namely,
Mental Hygiene, the Medical Jurisprudence of Insanity, and a volume of
Contributions to Mental Pathology, but neither of these books was a
general treatise on insanity. We simply note the curious fact without
attempting to explain it.

The author says of himself in his preface that, although he cannot
claim to have seen as many cases of insanity as an asylum superintendent,
yet a single case thoroughly studied is worth more as a lesson than a hun-
dred that are simply looked at, and often from afar off.

The manner in which he has made use of his personal experience in
giving illustrations of the various forms of insanity is certainly note-
worthy ; and in numerous instances histories of patients by themselves,
their relatives, or friends, are given, and add interest to the pages. The
case-books of Dr. R. L. Parsons, late the medical superintendent of the

522

Reviews.

[Oct.

New York City Lunatic Asylum, have also been drawn upon for much
interesting original material. We believe that the prominence which has
been given by Dr. Hammond to the recital of illustrative cases will do
much to stimulate more careful and elaborate note-taking in our institu-
tions for the insane.

Dr. Hammond's work is divided into four sections. Section I. treats
of the general principles of the physiology and pathology of the human
mind; Section II. of instinct, its nature and seat; and Section III. of
sleep; Section IV. is occupied with the description and treatment of in-
sanity, and constitutes about two-thirds of the book. In the first section
subjects of the utmost importance to one desiring to take up the further
study of insanity are discussed — the nature and seat of mind, and its
divisions, eccentricity, idiosyncrasy, genius, habit, age, sex, etc. The
discussion of instincts and sleep, although highly instructive and enter-
taining, has been carried out at too great length for a practical treatise on
insanity. The chapters on sleep and dreams are largely reproductions of
a former work by the author on sleep and its derangements. He says that
a knowledge of the physiology and pathology of this function should form
the groundwork of the study of insanity.

Dr. Hammond's definitions are generally clear, direct, and of no un-
certain sound. Mind is a force produced by nervous action, and in man
especially by the action of the brain. He divides this force into sub-
forces — perception, intellect, emotions, and will. Perception is that part
of the mind whose office it is to place the individual in relation with ex-
ternal objects. It is the starting-point of all ideation. Dr. Hammond
holds that there are reasons for believing that all sensations are formed in
the optic thalami. He devotes but little space to the discussion of the
intellect, a defect, considering the prominent place which intellectual
insanities hold in- his classification. He holds the intellect to be that
mental region where perception is resolved into an idea. An emotion is
that pleasurable or painful feeling which arises in us in consequence of
sensorial impressions or intellectual action. The will is that mental force
by which the emotions, the thoughts, and the actions are controlled. The
diagrams showing the connection of an organ of special sense with its
perceptive ganglion, and the mechanism of the development of ideas,
emotions, and volitions, are very simple, but none the less useful and
instructive.

The definition of insanity occupies so much attention in many of our
trials, where insanity is plead for the criminal, that we will quote Dr.
Hammond's definition.

u Insanity is a manifestation of disease of the brain, characterized by a general
or partial derangement of one or more faculties of the mind, and in which, while
consciousness is not abolished, mental freedom is weakened, perverted, or de-
stroyed."

He speaks in flattering terms of the definition proposed by Dr. Thomas
K. Cruse, namely, that "insanity is a psychic manifestation of brain-dis-
ease ;" but suggests adding to it the words " unattended by loss of con-
sciousness," making it read, " a psychic manifestation of brain disease
unattended by loss of consciousness." We agree with him that this defi-
nition is an admirable one.

We will also give entire the classification of Dr.'Hammond, as it is an
attempt to embrace all well-established varieties of mental alienation, and
will, therefore, at a glance give some idea of the present status of psy-
chiatry. The author holds that a system of classification should not only,

1883.]

Hammond, Treatise on Insanity.

523

as far as practicable, embrace all well-established varieties of mental alien-
ation, but it should also, at least, make the attempt to arrange them in
groups, according to whatever philosophical idea may exist in the mind of
its author.

"The system adopted may be wrong, it may be artificial and strained, it may
lack exactness and sharpness, in its boundaries, but nevertheless it is better than
none, and will at least, by exciting thought in the mind of the reader, lead to dis-
cussion, and, perhaps, a better system."

The classification is as follows : —

I. Perceptional Insanities. — Insanities in which there are derangements of one
or more of the perceptions.

a. Illusions.

b. Hallucinations.

II. Intellectual Insanities. — Forms in which the chief manifestations of men-
tal disorder relate to the intellect, being of the nature of false perceptions (delu-
sions), or clearly abnormal conceptions.

a. Intellectual monomania with exaltation.

b. Intellectual monomania with depression.

c. Chronic intellectual mania.

d. Reasoning mania.

e. Intellectual subjective morbid impulses.
/. Intellectual objective morbid impulses.

III. Emotional Insanities. — Forms in which the mental derangement is chiefly
exhibited with regard to the emotions.

a. Emotional monomania.

b. Emotional morbid impulses.

c. Simple melancholia.

d. Melancholia with delirium.

e. Melancholia with stupor.

f. Hypochondriacal mania or melancholia.

g. Hysterical mania.

h. Epidermic insanity.

IV. Volitional Insanities. — Forms characterized by derangement of the will,
either by its abnormal predominance or inertia.

a. Volitional morbid impulses.

b. Aboulomania (paralysis of the will) .

V. Compound Insanities. — Forms in which two or more categories of mental
faculties are markedly involved.

a. Acute mania.

b. Periodical insanity.

c. Hebephrenia.

d. Circular insanity.

e. Katatonia.

/. Primary dementia.

g. Secondary dementia.

h. Senile dementia.

i. General paralysis.

. VI. Constitutional Insanities. — Forms which are the result of a pre-existing
physiological or pathological condition, or of some specific morbid influence
affecting the system.

a. Epileptic insanity.

b. Puerperal insanity.

c. Pellagrous insanity.

d. Choreic insanity, etc.

VII. Arrest of Mental Development.

a. Idiocy.

b. Cretinism.

524

Reviews.

[Oct.

Some of the forms of insanity here given an abiding place — such, for
instance, as hebephrenia, katatonia, aboulomania, etc. — may be new to
many, although not unfamiliar to those acquainted with recent neurological
and psychiatrical literature. Hebephrenia is the term applied to the
insanity of pubescence, a form of mental derangement which presents
many characteristic features, and which, as the name implies, is peculiar
to that period in both sexes when the organism is undergoing the changes
incident to full development. Katatonia is a form of insanity characte-
rized by alternate periods supervening with more or less regularity, of
acute mania, melancholia, and epileptoid and cataleptoid states, with
delusions of an exalted character and a tendency to dramatism. Aboulo-
mania is a term proposed by Dr. Hammond to describe a form of insanity
characterized by an inertness, torpor, or paralysis of the will. Billod
first called attention to this condition.

The article on reasoning mania is one of the most interesting in the
book, although the profession and public have already become familiar
with it during the notable discussion on the case of Guiteau. This case
of Guiteau is the first of reasoning mania in which the brain has been
examined. The patho-anatomical condition was practically that of in-
cipient general paralysis.

Dr. Hammond's presentation of such medico-legal subjects as sane and
insane delusions, lucid intervals, etc., is of such character as to make the
book of value as a work of reference in the jurisprudence of insanity. His
views with reference to the question of lucid intervals are that full com-
plete intervals in the course of an attack of insanity, during which the
individual is well, and would so be pronounced by competent observers,
are exceedingly rare ; and that they are only to be found in recurrent
mania and a few other forms of insanity. Remissions are common
enough, but a remission is not a restoration to health, and the patient in
whom it is exhibited ought not to be regarded as being possessed of legal
responsibility.

Minor defects, and even some of considerable magnitude, are to be
found ; but they are not such as to mar the work as an exponent of
modern mental medicine. A careful condensation of opinions would
sometimes have been better, rather than the multiplication of too lengthy
quotations. Closer discussion of disputed points would often have been
more profitable than repetition of illustrations, however interesting the
latter.

Even in the chapter on treatment the entertaining is not absent, as
where, for instance, the author recounts the so-called " moral " treatment
of Leuret, which consisted in reasoning with the patient relative to the
falsity of his delusions, and if he persisted in maintaining them, notwith-
standing the arguments adduced, of subjecting him to the cold douche
on his head and body generally till he announced that he was convinced.

The times are ripe for a new work on insanity, and Dr. Hammond's
great work will serve hereafter to mark an era in the history of American
psychiatry. It should be in the hands of every physician who wishes to
have an understanding of the present status of this advancing science.
Who begins to read it will need no urging to continue; he will be carried
along irresistibly. We unhesitatingly pronounce it one of the best works
on insanity which has yet appeared in the English language.

C. K. M.

1883.]

Saint-Germain,' Orthopaedic Surgery.

525

Art. XX. — Chirurgie Orthopedique. Therapeutique des Difformites con-
geni tales oil acquises.^ Par le Dr. L. A. Saint-Germain, Chirur-
gien de l'Hopital des Enfants-malades. 8vo. pp. 7, 651. Avec figures.
Paris : J. B. Balliere et Fils, 1883.

Orthopcedic Surgery. Treatment of Congenital and Acquired Deformi-
ties. By Dr. L. A. Saint-Germain, etc.

The French books on orthopaedics, published only about fifty years
ago, are distinguished by a profusion of pictures representing complicated
apparatus for the treatment of deformities of the spine — beds, chairs,
swings, ladders, see-saws, ropes to climb, and a hundred other things of
this kind. The French book before us is remarkable for an almost total
absence of such cuts, while, on the other hand, it contains most elabo-
rate engravings to illustrate ablation of the tongue, the anatomy of the
eye, the operation for strabismus, the condition of and operation for
imperforate anus and hypospadias, as well as figures of the tracheotomy
tube and simple artificial limbs. To whatever this may indicate of the
scope of the book may be added, that it treats also of such heterogeneous
subjects as malformations of the nose, ears, and teeth, congenital hyper-
trophy of the tongue, fissure of the palate, erectile tumours and naevi,
umbilical malformations, hernia, exstrophy of the bladder, infantile pa-
ralysis, polydactylism and syndactylism, and obesity ; in addition to the
deformities which are usually thought of when orthopaedics are men-
tioned.

To include all these it was necessary that the author should formulate
a new definition of orthopaedics. And he did so, claiming that the study
of orthopaedics embraces all deformities, congenital or acquired ; in other
words, that it is a sort of cosmetic art.

This wide range of study has introduced the most serious defect of the
book before us. It is too large ; and there could be well spared from its
pages many which do not add a value proportionate to their number.
This objection being made, however, there is little to find fault with.
The author's views are in the main a faithful reflex of the prevailing
opinions in regard to the pathological conditions and treatment of deformi-
ties. It is not only clear that he is familiar with the best that has been
written in England, as well as in France, upon this subject, but every-
where are to be found the evidences of experience to justify or to correct
the affirmation of others. The author conveys his own opinion in a pleas-
ant, often amusing, and sometimes humorous, style. He dwells mourn-
fully upon the " decadence of the nose," and, while stating that it can-
not be accounted for because of a decadence in suckling, states, also, that
he does not think it attributable to the decrease in the habit of snuff-
taking. In speaking of harelip, he cites Bouisson as glorifying Provi-
dence for the rarity of the most dangerous form of this malformation,
and takes that occasion to warn his students against the tendency to
bring in u final causes." When he denies the truth of what are called ma-
ternal impressions, he tells a story of a pregnant woman who came to him
saying she knew she would give birth to a squirrel, because one had lately
leaped on her shoulders and frightened her. Instead of taking the path
most men would have struck into under such circumstances, he first assured
the prospective mother how easy a confinement she would have in case it
turned out as she anticipated. In another place he calls his students'

526

Reviews.

[Oct.

attention to a peculiar, but not an unknown, paradox in surgery in these
words: "You have all seen . . . those enormous tumours, which, when
measured daily, diminished two millimeters each day, and which at the end
of the year had increased one-half." The entertainment afforded by such
jeux 6? esprit receives an addition of surprise when, in a scientific work of
this character, and written by a Frenchman, one finds an allusion to
Dickens's u fat boy," or to the city of Cincinnati as " Porcopolis," or a
deprecation of an English surgeon's commentary on Sayre's method of
treating scoliosis — that it was " hanging a man and then taking a cast of
him." What could be more striking, more unlikely to be forgotten, than
an opinion expressed as follows ? "A scoliotic child is placed in the mid-
dle of a well-filled amphitheatre, when a few competent men, rari ?iantes,
are found in the midst of a crowd of assistants, entire strangers to the
subject. The child is shown on all sides, and presents a superb lateral
deviation. He is placed before a gauge, and his height is found to measure,
I will suppose, 1.42 metres. At once the chin-band and halter are ap-
plied. The child is swung to the breezes, and, thanks to previous repeti-
tions, bears the ascent very well. Immediately the assistants precipitate
themselves upon him and swathe him in a plaster jacket, . . . which dries
with astonishing rapidity. The apparatus once dry, the child is laid
on the ground; he is brought back to the gauge; he measures 1.45
metres. Result : 3 centimetres gained. General enthusiasm. Apotheosis."
And how complete the idea when, after describing the loosening of the fit
of the jacket in a few days, and the determination of this fact, in a ward,
the author adds : "The amphitheatre is not there. You cannot get the
enthusiasts of the day before together again, to show them the annulment
of the marvellous result. Their position is settled. They have witnessed
a miracle, and go everywhere propagating error." Again, in reference to
early operations for harelip, done by accoucheurs, we read : " If we were
still in the times when the different provinces of the medical art foraged
upon their reciprocal frontiers, and undertook, a propos of these limits,
veritable wars, one could not fail to say that the accoucheurs made haste
to operate upon the little patients while they had control of them, or that,
justly impressed with the sad tribute which the first years of early infancy
pay to mortality, they were unwilling that harelips should disappear with-
out having enriched science with their observation."

So much for our author's style, which is further enlivened by admirable
historical and other references to both ancient and modern authors. The
matter of his work is excellent. It might be objected that lie finds too
much to complain about in others, and it could hardly be claimed that
his preface is a model of modesty. Nevertheless, his book is a valuable
and an interesting one. If it were less so, it would never be read. As
it is, we think it ought to be, and will be. C. W. D.

1883.] Ziegler, Pathological Anatomy and Pathogenesis.

527

Art. XXI A text-book of Pathological Anatomy and Pathogenesis. By

Ernst Ziegler, Prof, of Pathological Anatomy in the University of
Tiibingen. Translated and edited for English students by Donald Mac
Alister, M.A., M.B., Member of the Royal College of Physicians, Fel-
low and Medical Lecturer of St. John's College, Cambridge. Part I.
General Pathological Anatomy, pp. 360, figs. 117. London, Mac-
millan & Co. 1883.

From the able translator's preface we learn that this excellent work of
Prof. Ziegler's grew out of attempt to revise Forster's well-known manual
of pathological anatomy, which it was gradually found would be almost
equivalent to writing a new treatise, and the latter alternative was there-
fore finally adopted. Prof. Ziegler explains that a great part of his text
is based upon observations made or verified by himself, and when he has
drawn from other sources the needful authorities have been carefully cited.
The present English version was begun on the basis of the first German
edition, but a second edition was so quickly called for in Germany, that
time was secured to embody in this, valuable additions made by the author,
together with many improvements agreed upon by Dr. Ziegler and
his English translator. The latter states that he has besides added full
notices of many French and English memoirs which throw light upon
subjects treated of in the text.

The style of this book is far superior to the rugged and idiomatic one,
which is too often inflicted upon students in translations from the German.
In fact it leaves little to be desired in the way of elegance, correctness, and
perspicuity. Its method of arrangement is admirable, its descriptions
often models of clearness and brevity, and its illustrations, which really
do illustrate, are numerous, superbly executed, and in most instances so
minutely accurate, that they might be mistaken for copies of photo-micro-
graphs from the diseased tissues themselves.

The first section of the book is devoted to malformations, treating of
deformities in single individuals, and of double monstrosities. In Sec-
tion II. are considered anomalies in the distribution of the blood and the
lymph. Sections III. and IV. are devoted respectively to the retrogressive
and progressive disturbances of nutrition, whilst Section Y. discusses in-
flammation and inflammatory growths, under which in a subdivision of
u The infective granulomata" are grouped tubercle, syphilis, leprosy,
lupus, glanders, and actinomycosis. The important subject of tumours
fills the fifty-nine pages of Section VI.; and Section VII. on parasites,
though last, is the newest and most important of all, at least from the
stand-point of the great medical science of the future — preventive medicine.

The dwindling minority of progressive physicians who still shut their
eyes to microscopic evidence, and " don't believe in bacteria," will find
little aid and comfort in Chap. XXX., which devotes over forty pages to
the schizomycetes or bacteria, their morphology, development, and patho-
logical effects upon the human organism. This full recognition in a sys-
tematic work of the momentous fact that general diseases are produced by
organic entities, which scarcely a decade since was practically ignored by
such representative German pathologists as Rokitansky and Eindfleish,
and more recently was but briefly touched upon by Wagner and Orth,
marks an important epoch in the history of the germ theory of disease,
and opens the way for a far more general conception of the zymotic affections

528

Reviews.

[Oct.

as being the expressions of a constant "struggle for existence" between
our own cell elements and low forms of vegetable life (as real and tangible
enemies to human existence as is the trichina or the rattlesnake), the
growth and development of which within the human system produce the
dangerous and often fatal symptoms of the maladies in question.

Our author follows Colin in his well-known classification into sphnero-
bacteria, microbacteria, desmobacteria, and spirobacteria, and quotes the
corroborative statement of Koch, whose long-continued experiments show
"that each species of bacteria possesses characteristic and easily recogni-
zable peculiarities in respect of structure, form, size, and mode of growth
of its colonies upon the gelatin" whereon the experiments were conducted.

In connection with the interesting subject of the conditions of life for
bacteria, obviously so important to the practical physician, because his
best remedies in the zymotic diseases must be those which will most satis-
factorily check growth and development in the schizomycetes, we find it
stated that a certain amount of oxygen is necessary to the reproduction of
many forms, but that pure oxygen gas is said to kill them outright. Some
curious and valuable information is given in regard to the temperatures
above and below which growth of the bacteria ceases ; thus it is stated
that development of all kinds terminates at a temperature of 5° C, t he
bacteria becoming stiff and immobile, although they are not absolutely
killed even by very extreme degrees of cold. The knowledge of this latter
fact seems to explain the remarkable renewal of yellow fever upon the U. S.
S. S. Plymouth a few years since, and would have promptly ended the
plausible but worthless scheme for destroying yellow fever germs by cold,
involving an expenditure of several hundred thousand dollars, which was
almost successfully urged through Congress during our last great epidemic.
Under the head of influence of non-nutritive or foreign substances in the
nutrient liquid, are considered the action of different bacteria upon eacli
other, and also the effect of various mineral and other substances, consti-
tuting the invaluable group of disinfectants. Among these chief weapons
in the sanitary armamentarium, corrosive sublimate is given on the au-
thority of Koch, AVolfhiigel, and others the first place.

The bacteria are divided by our author from a pathological stand-point
into, 1st, those which are passing all the time through the human body,
without being able to find in it conditions favourable for their development ;
2d, those which find their appropriate soil in the perfectly healthy organ-
ism, in which they grow and multiply ; and 3d, " those which are unable
to settle in a perfectly healthy body, but can only develop when the phy-
sico-chemical condition of the tissues is morbidly altered so as to correspond
with their requirements." The two latter of these varieties are grouped
together under the title of the Pathogenous bacteria, and comprise, of
course, the chief representatives of interest to the physician and pathologist.

It would occupy too much space for us to enter upon a detailed review of
all this important chapter, and we will therefore merely remark, en passant,
that Fig. 76, showing a section containing colonies of micrococci from the
vocal cord of a child ; Fig. 77, exhibiting micrococcus septicus in hepatic
capillaries, with necrosis of the liver cells ; Fig. 78, bacillus anthracis,
liver cells unaffected; Fig. 79, displaying under a low power the first
stage of hepatic abscess depending on obstruction of a venule by pyemic
micrococcus, and Fig 80, picturing Koch's bacillus tuberculosis, all admir-
ably represent these important downright facts in pathological histology,
and are therefore worthy of most attentive study.

1883.] Transactions of Medico-Chirurgical Society of Edinburgh. 529

Chapter XXXI. upon the hyphomycetes and blastomycetes (moulds
and yeasts) as pathological agents, and Chap. XXXII. upon the animal
parasites, are both elaborate yet concise, and continue the same display of a
master's hand, in the work of description and explanation, which charac-
terizes the earlier portions of the volume.

Perhaps it is hardly just either to the author and translator or to our
own readers, to judge this book by the portion which is now before us,
but if the promise here given is fulfilled in Part Second, devoted to special
pathological anatomy, we feel sure that a systematic text-book will be
supplied, so fully abreast of the advances recently made in this most pro-
gressive of the medical sciences as to render it extremely valuable to
practitioners and students alike — one which must accomplish much to-
wards securing for pathological anatomy its rightful place, as the chief
corner-stone of all true medical science. J. G. R.

Aet. XXII The Transactions of The Medico-Chirurcjical Society of

Edinburgh. Vol. I. Session 1881-82. 8vo. pp. 188. Oliver and Boyd,
Publishers to the Society, Edinburgh, 1882.

Although founded in 1821, this is the first year in which the trans-
actions of the society have been published in book form. By the cata-
logue of members given, we find that there are 151 resident, and 85
non-resident members. Dr. George W. Balfour is the President of the
Society, having been elected for two years, in January, 1882. The society
holds nine meetings in the year, and the sessions are of general interest,
as a great variety of subjects are presented ; patients are introduced, and
morbid specimens, miscellaneous objects, surgical appliances, casts, draw-
ings, photographs, etc., are exhibited. Eighteen original papers were
read and discussed ; ten patients exhibited ; twenty pathological specimens
shown ; six foreign bodies, also ; besides surgical appliances, photographs,
etc. Original communications were presented upon the following varied
subjects.

1. Anatomy of the pia mater, by Dr. J. Beatty Tuke, M.D.

2. Hereditary transmission of disease, by George Leslie, M.D.

3. Action of the auricles in health and disease, by George A. Gibson,.
M.D.

4. Arguments in favour of the theory of dilatation of the heart as the
cause of cardiac hasniic murmurs, and of the appendix of the left auricle
being the primary seat of this murmur, by George TV. Balfour, M.D.

5. The murmurs of debility in the pulmonary and tricuspid areas, by
William Russell, M.D.

6. Xotes on the position and mechanism of the hsemic murmur, by
George W. Balfour, M.D.

7. A case of diabetic coma with Lipasruia, by Prof. Thomas P. Fraserr
M.D.

8. Some of the sequela? of acute infectious diseases in children, by
James Carmichael, M.D.

9. Alternation, Periodicity, and Relapse in mental diseases, by Thomas
S. Clouston, M.D.

10. The causes of tinnitus aurium, by P. McBride, M.D.
No. CLXXII Oct. 1883. 34

530

Reviews.

[Oct.

11. The treatment of syphilis, by Francis Cadell, M.D.

12. On the treatment of fresh wounds, by John Duncan, M.D.

13. On accidental experiment with antiseptics, by the same.

14. Cranial injuries, by Prof. John Chiene.

15. Case of intestinal obstruction, treated by opening the abdomen, by
Mr. Joseph Bell.

16. Notes on rupture of the urethra, and its treatment, by Mr. Joseph
Bell.

17. Cases of stricture of the urethra, by Francis Cadell, M.D.

18. On a rare form of senile gangrene, by Mr. Joseph Bell.

Many of these papers are very creditable to their authors, and are
made of additional value to the reader by the able discussions which are
reported as appendices to them. We cordially recommend the volume as
one containing much that is interesting and instructive. R. P. H.

Art. XXIII. — A History of Tuberculosis from the Time of Sylvius to
the Present Day, being in part a translation, with Notes and Additions,
from the German of Dr. Arnold Spina; containing also an Account
of the Researches and Discoveries of Dr. Robert Koch and other Recent
Investigators. By Eric E. Sattler, M.D. 12mo. pp. 191. Cin-
cinnati : Robert Clarke & Co., 1883.

It is a great convenience to English readers to be able to read Spina's
Studies on Tuberculosis in our own language ; and for this opportunity,
as far as it is presented, we are indebted to Dr. Sattler. At the same
time it diminishes this satisfaction to find that only five sections of Spina's
work are thus translated, and that this is followed by two chapters in which
it is sought to bring the history of tuberculosis down to the present time,
including a full description of the latest experiments of Dr. Spina himself.
Spina's own researches included 55 pages out of 122 pages of the original
work, but 67 being devoted to the history ; while in Dr. Sattler's book,
out of 184 pages, 124 are occupied with the translation of Spina's history
of tuberculosis, and but 60 are devoted to recent researches, including a
full account of those of Koch and others, as well as those of Spina. The
apparently necessary conclusion is that it is neither one thing nor the other,
neither a translation of Spina nor a history of tuberculosis by Sattler. We
think, however, that a sufficient proportion of the book is purely Spina's
work to demand that his name, and not Sattler's, should appear on the
back of the volume. Had the book been one of 300 or 400 pages, which
might easily be written upon the subject, an introduction, consisting of a
translation of Spina's history, might have formed a part of it with no other
acknowledgment than that in the title-page and preface.

As to the matter written by Dr. Sattler himself, the account of Koch's
experiments, as well as that of other investigations since Koch's first
paper, will be found very interesting reading, and the methods employed
by the various investigators, as detailed by Dr. Sattler, most convenient for
reference. If the literature of the subject grows as rapidly in the second
as it did in the first year after Koch's announcement, a new edition of the
book will soon be required, when we hope to see the names of Spina and
Sattler on the back. J. T.

1883.]

Disease Germs.

531

Art. XXIV Disease Germs.

1. The Bacteria. By Dr. Antoine Magnin, Licentiate of Natural

Sciences, Chief of the Practical Labours in Natural History to the
Faculty of Medicine of Lyons, etc. Translated by George M.
Sternberg, M.D., Surgeon U. S. Army. 8vo. pp. 227. Boston :
Little, Brown & Co. 1880.

2. Bacteria : the Smallest Living Organisms. By Dr. Ferdinand

Cohn. Translated by Dr. Charles S. Dolley. Pamphlet, pp.
30. Rochester, N. Y.

3. Bacteria and the Germ Theory of Disease; Eight Lectures de-

livered at the Chicago Medical College. By Dr. H. Gradle,
Prof, of Physiology, Chicago Medical College. 8vo. pp. 219.
Chicago : W. T. Keener, 1883.

4. On the Relations of Micro-Organisms to Disease. The Cartwright

Lectures delivered before the Alumni Association of the College
of Physicians and Surgeons, New York. By William T. Bel-
field, M.D., Lecturer on Pathology and on Geni to-Urinary Dis-
eases, Push Medical College, Chicago. 16mo. pp. 131. Chicago :
W. T. Keener, 1883.

The literature of micro-organisms and of their relations to disease has
increased to such an extent that some effort at systematic arrangement of
our knowledge is not only justified, but necessary to any one who desires to
familiarize himself with it. One of the most valuable of these is the work
of Magnin, translated by Dr. Sternberg, containing all that is essential as
to history and morphology, while the role of the bacteria in contagious and
virulent diseases is well described to the date of publication. Very useful,
too, will be found the pamphlet of Cohn, whose name is better known in
connection with bacteria than that of any other naturalist, translated by
Dr. Dolley, while a student of medicine in the University of Pennsylvania.
The smaller books of Dr. Belfield and Gradle are upon the same subject,
which is extended to include the important more recent application to tuber-
culosis. The two books supplement each other in certain respects ; so that
the reader who desires to be well informed may read both with advantage.
Dr. Gradle's work is almost purely historical, while Dr. Belfield has evi-
dently a leaning towards the infectious nature and parasitic origin of
tuberculosis, and he seeks to strengthen his position whenever he can, and
of course to weaken the other side. We cannot but think he has ignored
a few points on that side which should have been brought forward. The
lectures are, however, a valuable introduction to the subject, and should be
read by all interested in it, as should also those of Dr. Gradle.

It is out of the question, and indeed would scarcely be profitable
under the circumstances, to attempt to give the scope of the subject. But
to those who have not kept themselves au courant with the literature
covering the relation of micro-organisms to disease, it may be interesting
to- know that the number of diseases in which bacteria are found, either in
the secretions, the blood, or the tissues, is so far increased as to include
suppurating wounds, abscesses, furuncle, osteomyelitis, pyaemia, traumatic
fever, erysipelas, gangrene, phlegmon, malignant oedema, charbon, tuber-
culosis, glanders, typhoid fever, relapsing fever, smallpox, cowpox, sheep-
pox, measles, malaria, diphtheria, leprosy, sypbilis, milk fever, gonorrhoea,
and gonorrhosal conjunctivitis, trachoma, croupous pneumonia, endocar-
ditis, sympathetic ophthalmia, whooping-cough, rhinoscleroma, pterygium,
rhus-poisoning, and other less known conditions. J. T.

532

Reviews.

[Oct.

Art. XXY. — De V Excision du Goitre Parenchymateux. Par Le docteur
Paul Liebrecht, Assistant a l'Universite de Liege, Ext. du Bulletin
de l'Academie Royale de Aledecine de Belgique ; 3e Ser., t. xviii., No. 3.
8vo. pp. 270. Bruxelles : H. Aianceaux, 1883.

The Excision of Parenchymatous Goitre. By Dr. Paul Liebrecht, etc.

No one who bas not undertaken a work like this can appreciate cor-
rectly the immense amount of labour it represents, or approach the criticism
of it with the degree of sympathy it demands. About 3-30 cases of opera-
tion for removal of the diseased thyroid gland have been collected, analyzed,
and compared ; the details of many have been reproduced ; the history of
the operation has been studied; its theoretical and practical merits have
been carefully weighed, and certain conclusions — the outcome of all this
research — are stated for the benefit of those who have not the time or
opportunity to go over all the ground for themselves. These conclusions
are only in part drawn from what the author has reproduced. They have
been forced upon his mind by countless details, only a certain proportion
of which could possibly be included in his book. For this reason, and
more assuredly because no large number of readers are likely to have the
patience to go through even what he has recorded, it is hardly to be ex-
pected that his views will soon be fully accepted. Nevertheless, they will
undoubtedly secure respectful attention, and his unwearying devotion to
his subject will not go unrewarded.

His preliminary remarks indicate the thoroughness of his research, and
show that he appreciates one of its greatest merits — that of furnishing a
repertorium, where other authors may find the facts necessary to the forma-
tion of an individual judgment. With this in view, he has noted, as far
as possible, in each report : the sex and age of the patient ; the date of
operation ; the description of the goitre ; the accidents to which it gave
rise and the indication for operation ; the details of the operation ; the
results of the operation ; the final issue ; other unclassified points ; the
name of the operator, and the source from which his account is drawn.

The reports are classified according to the nationality of each operator :
the German, Austrian, and Swiss being put together and amounting to
226 ; the French amounting to 34; the English to 30 ; the American to
16 ; the Italian to 10 ; the Prussian to 3 ; the Swedish to 1 ; and the Bel-
gian to 2 — a total of 322 operations. Of these 250 were cured, 64 died,
2 were not completed, and in 5 the result is uncertain. He adds, without
details, 29 cases of Billroth's and 5 of Chelius's — 29 cured and 5 ending
fatally, which gives in all a total of 356 with a mortality of 69, or 19.39
per cent.

A special section is devoted to the history of the literature of goitre,
going back to Hippocrates, and correcting certain errors in regard to the
views and statements of some of the ancients, quoting their ipsissiina
verba. The first author to whom Dr. Liebrecht credits a report, in pre-
cise terms, of an extirpation of a goitre is Fabricius Hildanus, whose
account he quotes almost in full. This operation was done upon a child
by a quack after Hildanus had refused to undertake it. The child, a girl,
died under the knife of the operator. In the eighteenth century the ope-
ration was performed a few times, though as late as 1794 Wichmann
characterizes it as " in good German literally cutting the throat of one's
patient." Even Bardeleben, as late as 1875, repudiated the operation,

1883.] Liebkecht, Excision of Parenchymatous Goitre. 533

while Erichsen, 1878, says the operation "is seldom to be thought of."
The first surgeon in France who warmly advocated it was Michel, in
1873. In other countries it was until recently held in equally low esteem.
But, at present, owing to the wonderful success of Billroth, Liicke, Bruns,
Kocher, and others, it is growing into more general adoption, and in France
the author speaks of it as acquiring popularity. "It is especially," he
says, " since the second half of this century, and more particularly since
a dozen years, that thyroidectomy ha» conquered an established position
among legitimate surgical operations. Actually the number of known
total extirpations exceeds 400, of which the great majority have been
crowned with success." This change he compares with the history of
ovariotomy, and claims that, equally with the latter operation, the excision
of a goitre is demanded whenever not specially contraindicated.

Following this the author devotes a section to the descriptive and topo-
graphical anatomy of the thyroid gland and of goitre. Next he takes up
its pathological anatomy and its influence on neighbouring organs. Next
come the indications and contraindications for the operation, naturally at-
tributing great weight to Billroth's opinions. His own conclusions he
formulates as follows : —

"One should operate: when other means have failed and if the accidents"
have acquired gravity, or when one can foresee that they will acquire it at a given
period. The last result can be anticipated when there is a continual increase of
the goitre. One may operate : to get rid of a deformity, either for aesthetic rea-
sons or when it constitutes for the patient an obstacle to his occupation or his
social relations ; or, in fine, when the tumour, without determining accidents,
properly so called, is the cause of annoyance or inconvenience to the patient."

He makes a point of the danger of delaying the operation, and cites the
valuable paper of Kocher on the Indications for the Extirpation of Goitre
in the Present Position of Antisepsis, published in the Correspondenz-
blatt f. Schweizer Aerzte, 1878, No. 23, to bear him out in his opinions.
He admits only one absolute contraindication — atheromatous degeneration
of the arteries.

As to total or partial excision, the statistics are slightly in favour of the
former ; and he would limit partial excision to goitres clearly pediculated
or circumscribed and isolable from the surrounding tissues. Above all,
one must not leave behind any diseased tissue, for fear of recurrence.

The method of operating described includes mixed anaesthesia and anti-
septic dressings — the spray Liebrecht considers superfluous. Every detail
of the operation is described most carefully, and with the greatest particu-
larity, and the method of Baumgartner (Ceutralblatt f. Ohirurgie, 1881,
No. 3), for the control of hemorrhage, strongly recommended. This
method consists in dissecting the tumour out, seizing each bloodvessel or
fibrous band as encountered with two " pinces hemostatiques" 'and divid-
ing between these, leaving both in place. When the tumour is removed
the hemostatic forceps are taken off one by one. Many will be found to
contain no bloodvessels, or such small ones that they do not bleed after
the pressure they have had. When a vessel does bleed it is to be carefully
isolated, and ligated. For ligatures the author prefers good catgut, hard-
ened in chromic acid — as Lister recommends — and advises cutting the
ends off and closing the knot up in the wound.

Preliminary tracheotomy does not appear to be approved by facts, and
it certainly is not recommended, unless in exceptional cases, by the most
distinguished and successful operators.

534

Be views.

[Oct.

The author advises the use of Lister's antiseptic dressings after the
operation.

The consideration of the sequela? of thyroidectomy leads to some most
interesting statements in regard to the wounding of nerves. The nerves
which may be injured are the pneumogastric, the inferior laryngeal, and
the great sympathetic. The first accident has never been observed in this
operation. But, even if it should, Liebrecht thinks it would not neces-
sarily entail unfortunate consequences. He cites a number of cases where
portions of the pneumogastric have been removed, in other operations,
without any ill effect whatever. Injury of the recurrent laryngeal nerves
by ligature or by section has occurred a number of times, followed by im-
pairment of phonation and deglutition, and even by bronchial inflammation
and tetanus. Whether the two latter sequences were consequences or not
does not appear clear, but it is doubtful that they were. The voice altera-
tions have usually passed off in a few weeks. The difficulty in swallow-
ing occurred in a bad case of Billroth's, and amounted to an impossibility,
the patient dying collapsed in forty-eight hours. Here, again, it is doubt-
ful that the ligation of the recurrent nerve with the inferior thyroid artery
was the cause of the trouble : first, because of the nature of the case, and
second, because, if it were, similar effects ought to have been observed
in some of the other cases where a similar accident happened.

As to the remote effects of excision of the thyroid, the author cites an
interesting communication of Kocher to the Berlin Congress, in which he
claims that there are few cases of operation in which general disturbances
do not follow. These troubles become more pronounced as time goes on.
They consist in dulness, lassitude, and progressive pernicious ancemia —
what Kocher calls the " goitrous cachexia." This assertion of Kocher's
was denied by Bardeleben and Wolfler — the latter of whom speaks, in a
sense, for Billroth. Liebrecht does not commit himself as to the facts,
but calls attention to their influence upon the whole question of total
extirpation.

In conclusion, the author analyzes his statistics to show the results of
the operation and the causes that have militated against its success. This
leads him to the statement that only about 8| per cent, of the deaths are
fairly attributable to inevitable causes, and that the excision of parenchy-
matous goitre has taken its place in surgical practice, and will shortly be
done under conditions similar to those affecting the removal of every other
kind of tumours.

The last pages of the book contain a full and useful bibliography of
the subject, and a table of contents.

From this brief epitome it may be seen how valuable a contribution to
surgical literature we have here. Instead of the arbitrary opinion of a
single operator, we have a collection of facts, to the proper estimation of
which the compiler's analysis and conclusion offer most useful assistance.
As far as we can judge, these conclusions are fully justified by the facts
cited, and it makes little matter that they are opposed to the opinion of
some surgeons whom the whole world holds in deserved respect. The
mountain will not come to Mahomet — Mahomet must come to the moun-
tain. C. W. D.

1883.]

Health Reports.

535

Art. XXYI Health Reports.

1. First Annual Report of the Board of Health of the State of New
Hampshire for the year ending April 30, 1882. Concord, 1882,
pp. 318.

2. Fifth Annual Report of the Board of Health of the State of Rhode
Island for 1882. Providence, 1883. Pamphlet, pp. 327.

3. First Report of the State Board of Health of Arkansas from April,
1881, to Dec. i882. Little Rock," 1883. Pamphlet, pp. 181.

1. The Neiv Hampshire Report, being the first after the establishment
of the Board of Health, deals chiefly with the mode of organization and of
preliminary work, although here, as elsewhere in so many parts of the
United States, has been found an unwelcome opportunity for practical
effort in battling against the spread of smallpox. A suitable bulk is
given to the volume by essays furnished by various members of the board
and others, which, without contributing any important additions to the
science of hygiene, are valuable to the inhabitants of the State, not only
as applying general sanitary rules to special local conditions, but also as
aiding in the dissemination of knowledge respecting those great principles
which regulate systematic care of the health.

From the secretary's report we find that the board is composed of three
physicians, one civil engineer, the governor, and the attorney-general,
these last two being ex officio members. As usual, the secretary is paid a
salary, but the other gentlemen receive no compensation, although their
actual expenses whilst on duty are allowed. The total sum appropriated
to the board is limited to $3000 annually.

Efforts to obstruct the development of local or general smallpox epi-
demics, especially by the liberal employment of vaccination, appear to have
met with highly gratifying success, several instances being recorded in
which the outbreak was restricted to the single individual first attacked.
In one case, imported from New York, the young man was supposed to be
suffering from chicken-pox, and isolation, etc. being therefore neglected,
he contrived to infect, directly and indirectly, thirty-eight persons, giving
rise to thirteen cases of smallpox, of whom eight died, and twenty-five cases
of varioloid, all of which recovered. The secretary also urges, ably and
forcibly, the importance of providing against typhoid fever from contami-
nated water-supply, and suggests some valuable cautions in regard to diph-
theria, the sanitation of seaside resorts, the use of impure ice, and other
kindred topics.

After an essay on Vaccination, by Professor C, A. Lindsley, M.D., of
Yale College, which is borrowed from the Report of the Connecticut State
Board of Health for last year, appears a useful article upon Ventilation, by
Dr. G. P. Conn, of Concord, President of the Board, in which is justly
argued the superior importance of plentifully supplying fresh air to dwell-
ings in the colder latitudes. Several of the wood-cuts with which this
paper is illustrated appear to have been loaned (doubtless not unwillingly)
by the manufacturer of a ventilating grate, which is highly praised. Next
follows a paper upon Suburban School-Houses, by Warren R. Briggs,
architect, of Bridgeport, Conn., which is illustrated by eleven plans, point-
ing out some of the best methods of avoiding those defects of sanitary con-
struction which are unfortunately too common in such edifices, and tend,
even in the schoolmaster's paradise of New England, sadly to counterbal-

536

Reviews.

[Oct.

ance the benefits of popular education, by sowing the seeds of physical
weakness and degeneracy among the youth of America.

Water Pollution, Public and Private, is the title of an excellent paper
from the scholarly pen of Dr. A. H. Crosby, of Concord, and although a
little imperfect, it is complete enough to save a vast amount of human suf-
fering and death if its practical suggestions were heeded by those to whom
it is addressed.

The Registration report, showing the number of births, marriages, and
deaths in the different counties, and an appendix containing the more im-
portant laws of the State bearing upon sanitation, conclude the volume,
which, as the first attempt of a newly-organized board of health, is highly
creditable, and gives promise of a good degree of future usefulness.

2. The diligent secretary of the Rhode Island State Board of Health
appears to have taken a lion's share of the work in preparing the report,
more than three-fourths of the volume being made up of his contributions.

From this document it appears that no great emergency requiring spe-
cial meetings of the board has arisen during the year, and the only im-
portant communications received by it were, one in regard to smallpox at
Newport, and another respecting the unsanitary condition of the State
House at Providence. Much regret was felt over the failure of Congress
to supply means to the National Board of Health to pursue its great inves-
tigation into the nature of the malarial poison, which the State Board had
already prepared the way for, and proposed to aid, as an inquiry likely to
benefit very largely the inhabitants of the United States. On account of
the parsimonious allowance to the board (only three hundred dollars an-
nually is appropriated by the Rhode Island Legislature), no original inves-
tigations could be undertaken, but sundry popular articles upon sanitary
subjects were published by the secretary as aids towards forming correct
public opinion upon these important matters.

According to the registration report, there were, during the year 1881, in
a population of 276,531, 6761 births (more than ever before recorded),
2750 marriages, and 5016 deaths ; the death-rate of the last five years is
given at the low figure of 17.2 per 1000. From the summary of the death
register we find that more than one-quarter of all the deaths which occur
in Rhode Island are caused by diseases of the lungs and respiratory pas-
sages. Consumption is the most fatal malady, and pneumonia stands next,
being followed by cardiac disorders and old age, to which 247 deaths are
attributed. Scarlatina, which stood second on the list in 1880, had, in
1881, dropped to the twelfth place.

A praiseworthy effort to obtain statistics in regard to the prevalence
and severity of the more common acute diseases, has not, we regret to ob-
serve, met with all the success it merited, only about thirty towns furnish-
ing the desired accounts. Full annual reports from the numerous medical
correspondents of the board in various parts of the State are given, but in
the absence of any complete tabulated statement of the results afford in-
formation of local value only.

The paper by Edwin E. C alder, on the Composition and Properties of
milk, is an exhaustive compilation of the main facts in regard to this im-
portant article of food, but it is chiefly valuable to an experienced sanita-
rian as narrating the author's own experience as milk analyst of the city of
Providence. After a five years' term of service, in which the lactometer
was applied to the testing of thousands of samples, he declares that, taken
in connection with the taste, smell, colour, and general appearance of the

1883.]

Health' Reports.

537

fluid, this instrument cannot fail to be of great service in examining the
milk from any dairy, or the supply of any large city, also that in no in-
stance have its readings caused any injustice to the milk-dealer. A sup-
plementary chemical analysis is often necessary to determine the percentage
composition in essential constituents and for the detection of foreign sub-
stances. This analysis, however, rarely requires to be complete, the de-
termination of the total solids, fats, solids not fat, and the amount and
nature of the ash, being generally sufficient. One shrewd provision of the
State law, which we would like to see enforced in our own city against
these Herods of the nineteenth century, is that any milkman convicted of
selling impure milk shall have his name and place of business " published
in two newspapers printed in the town, or county, where the offence has
been committed."

The other essay, on Parks and Ope?i Spaces in Cities, by T. C. Clark,
M.D., of Providence, is a brief, but earnest plea in favour of these popular
breathing- places, which do so much to reduce the sick and death-rate among
the children of the poor.

3. The Arkansas State Board of Health Report covers a period of
nearly two years from its establishment in April, 1881, to December,
1882, and records the struggles of a beneficent organization to be of use
to a people who seem to be scarcely educated up to the degree of appre-
ciating the infinite hygienic advantages which it would secure if properly
sustained by the community. Some idea may be gained of the difficulties
which are encountered by sanitary authorities among ignorant and pre-
judiced persons from the statement that the Local Board of Health of
Little Rock —

"During the early part of the year 1881, was doing good work in cleansing
the city. But the visits of the Sanitary Inspectors to the premises of the Mayor
and several of the Aldermen were regarded as infringements of their personal
rights ; and the indignation of the town Council was manifested in the repeal of
the health ordinances sanctioning such invasions, and in abolishing the Board of
Health. As a consequence, filth everywhere accumulated in disease-spreading
abundance. Ordinary diseases assumed aggravated forms, and did not respond
to treatment; sickness was general, and the mortality was nearly, if not quite,
double that of any period of like duration in the city's history."

As is apt to be the case in new civilizations, the most effectual work of
the State Board of Health was accomplished in the presence of contagious
diseases, particularly of smallpox, when the popular dread of a threatened
epidemic swayed public opinion strongly in favour of the sanitary officials.
Several examples of the beneficial effects of prompt isolation and vaccina-
tion in preventing the spreading of variola are reported, as, for instance,
the cases at Little Rock, seventeen of which were recorded, four in vacci-
nated patients with one death, and thirteen among unvaccinated persons
with nine deaths, a mortality of over two-thirds. In one of these series
of instances, the infection was believed to have been introduced by some
discarded underclothing, picked up and washed by the first person attacked,
who was a servant in the hotel where it broke out. On another occasion,
smallpox broke out among the passengers in a box-car upon the Memphis
and Little Rock Railroad. As neither of the towns between which it was
discovered would consent to receive the cases, the main track was cut, the
box-car containing the five cases side-tracked, and a physician, medicines,
and supplies being furnished by the railroad company, the patients were
cared for in this unusual way, along with two cases which afterwards

538

Reviews.

[Oct.

appeared in one of the neighbouring towns, without further extension of
the malady.

With every disposition to make liberal allowances for imperfections in
the work of a newly formed Board of Health, the operations of which have
been carried on in spite of such discouraging obstacles as those already
alluded to, we must deprecate the careless proof-reading in future Re-
ports which would represent the presiding officer as promulgating such
astounding declarations as the following, on p. 49, " Hygiene or public
health is that condition of body, supported by physical causes, such as air,
water, and food." Nearly half of the volume is taken up with a reprint
of Dr. Gihon's very able and important report on the prevention of vene-
real diseases made to the American Public Health Association, at its Xew
Orleans meeting ; with the Meteorological Report prepared by W. U.
Simons, of the U. S., a signal corps stationed at Little Rock ; and with the
mortuary report of Little Rock, showing a death-rate of nearly 40 per
1000 in a population of a little over thirteen thousand as given by the U. S.
census of 1880 ; although in fairness we should mention that local authori-
ties consider this figure too low, and place the number of inhabitants at
about 18,000, which would reduce the rate of death to 29 per thousand
annually. J. G. R.

Art. XXYII — Excision of the Knee-Joint, with Report of Twenty-
Eight Cases. Illustrated by thirteen Photo-Lithographs and Wood
Engravings. By George Edgeworth Fenwick, M.D., CM., etc.
8vo. pp. 68. Montreal : Dawson Bros., 1883.

In his preface the author states that, at the request of friends, he has
" thrown together a few observations on the subject of excision of the
knee-joint, principally with the object of placing on record the statistics of
the Montreal General Hospital in reference to that operation." He further
states that he has brought prominently forward a method of section of the
bones, to which he attributes much of his success. This method wras
given to the profession in the pages of the Canada Medical Journal some
sixteen years ago ; but it has not attracted the attention which it merits.
Justified by his own success, he again urges its adoption. It has the pecu-
liarity of including a removal of the opposite bone surfaces in a curvilinear
manner ; so that, when the shafts are brought into apposition, the newly
made convexity of one — the femur — shall fit into a corresponding con-
cavity of the other — the tibia.

This practical suggestion, which the author deems the most important
of those he makes, is accompanied, however, by others, occurring inci-
dentally, which add materially to the value of his brochure. Among
these may be set down the emphasizing of the need for personal supervi-
sion of the after-treatment by the surgeon himself. As the author remarks,
" A little trouble and attention in this respect will amply repay the sur-
geon." This truth is not limited to operations on the knee-joint.

The book opens with an argument, which is scarcely needed nowadays,
in favour of the operation of excision per se. But the author does not
lay down clearly the cases to which he believes the operation to be spe-
cially applicable, though he undertakes to do so ; and one is compelled to

1883.]

Fen wick, Excision of the Knee- Joint.

539

gather from the cases he reports that any chronic condition 'which inter-
feres with the use of the joint, as a joint, even though it cause but little
pain, justifies it in his opinion. It would almost seem as if his zeal for
the operation had led him at times to operate when others would have
hesitated ; yet the results obtained appear to have been satisfactory to
him and to his patients, and they would certainly be better judges than
one at a distance.

In the course of his remarks, the author takes occasion to express his
disbelief in the theory which would attribute joint disease to extravasa-
tion of blood into the cancellated tissue beneath the cartilage, relegating
the cause rather vaguely to sudden strains, twists, blows, wounds, and
cold, causing inflammation of the synovial membrane and subsequent
destruction of cartilage and involvement of bone.

But, when we come to what the author sets before him as his real object,
namely, describing a method of operating, we find him clear and full
enough in his statements. The method he advocates may be epitomized
as follows : An incision is made from the back of one condyle to the back
of the other, going below the patella, and dividing its ligament and the
lateral ligaments, after which the crucial ligaments are divided. Next
the articular surface of the femur is removed in such a manner as to leave
a semi-cylindrical end convex from before backward, and the articular end
of the tibia so as to present a corresponding semi-cylindrical concavity.
This the author does with a fine fret-work saw fitted to a Butcher's frame.
The condyles must be reduced to an equal extent, so as to preserve their
proper relations. The two ends must then be accurately adjusted. The
epiphyseal line is not to be disturbed, if it can possibly be avoided. The
hamstring tendons are to be let alone, unless they prevent putting the
bone in proper position. The patella is to be removed with its fibrous
investment. Hemorrhage is next to be checked, and suitable dressings
applied. The apparatus recommended is that of Dr. Patrick Heron Wat-
son, of Edinburgh, consisting of a rod of iron extending from the groin
to the toes, bent at the ankle to follow the line of the foot, and at the
knee so as to arch well above it. Dr. Fen wick has added two tin plates,
one to embrace partly the thigh, and one to do the same to'the upper part
of the leg, so as to prevent twisting. The bar has either one ring or
two, by which it can be swung. The lower part of the fixation apparatus
consists of a Gooch's splint, made to partly embrace the limb, and leave
the knee almost entirely free. The apparatus is applied with a paraffine
bandage before the wound is closed, and then this is done after the method
of Lister, the dressing being made to include the lower splint, but passing
below the arch in the rod above.

A second part of Dr. Fenwick's book contains detailed accounts of ten
cases, illustrated by nine photographs. The accounts are interesting, and
the pictures are admirable in their execution, giving the impression of
most favourable results in the author's operations.

Finally, there is a table of twenty-eight cases — twenty-one by Dr. Fen-
wick — with only one death. Comparing Dr. Fenwick's operations with
those published by other surgeons, they appear to have been more success-
ful, not only as to the mortality, but also as to the results obtained. (In
the body of his book (p. 13) Dr. Fenwick says there were two deaths in
twenty-eight cases, " only one of which can be ascribed as due to the
operation." The table, as just stated, gives but one death. It also
classes one result as doubtful, and includes two cases where amputation
had to be performed.)

540

Reviews.

[Oct.

So much for the matter of this book. The style is loose and unme-
thodical, the punctuation is sometimes very bad, and the language and
construction trying to the reader. There are a number of rather serious
errors of date, corrected in a slip of errata, and the very title-page con-
tains a misprint by which lithograph becomes " lithograhs". These faults
are not of great consequence as compared with the instructiveness of the
author's matter ; but they ought to be corrected if the book comes to a
second edition. C. W. D.

Art. XXYIII Types of Insanity: An Illustrated Guide in the Physical

Diagnosis of Mental Disease. By Allen McLane Hamilton, M.D.,
one of the Consulting Physicians to the Insane Hospitals of New York
City, etc. New York : Wm. Wood & Co., 1883.

The photographs from La Salpetriere, found in the works of Charcot,
Bourneville, and Regnaud, and others of the French school, have done so
much towards making the fame of these authors, that we have wondered
sometimes that the same comparatively easy method of spreading informa-
tion and acquiring reputation had not been more resorted to in other
countries than France. Dr. Hamilton has here utilized the method in
some studies of insanity. The plates were drawn from instantaneous
photographs, and the work lias been admirably done. The subjects were
selected from many hundreds of patients, and are typical. The forms of
mental disease illustrated by the plates are idiocy, imbecility, melancholia
attonita, chronic melancholia, subacute mania, chronic mania, dementia,
and general paresis

Certain acute affections of the ear, and the condition of the teeth in the
insane, are also shown in the last plate. In Fig. 6 of this plate, referred
to as syphilitic teeth, serrated and irregular lower teeth are represented.
Hutchinson's view, if we remember aright, was that only the condition of
the upper incisors was indicative of syphilis. The whole doctrine of
syphilitic teeth is doubtful. Notched, serrated, and irregular teeth of
various kinds probably represent mal-nutrition and arrested development
from various causes.

Descriptive text accompanies the illustrations, and an abstract of the
laws of various States with reference to the commitment of the insane is
added.

The work is an interesting contribution to psychiatry. C. K. M.

Art. XXIX — On the Treatment of Wounds and Fractures: Clinical
Lectures. By Sampson Gamgee, F.R.S.E., etc. Second edition,
8vo., pp. ix., 364. With 44 engravings on wood. Philadelphia : P.
Blakiston, Son & Co., 1883.

It is now so many years since Mr. Gamgee first enunciated his views
in regard to the principles most conducive to repair of surgical injuries,

1883.]

Gamgee, Treatment' of Wounds and Fractures.

541

that the mention of his name suggests at once the thought of his formula,
"rest, compression, dry and infrequent dressings." For this reason, on
taking up a book by him with such a title as is given above, one might
expect to find it simply an argument for his peculiar views, enforced by
illustrations drawn from his own experience. Such, indeed, in a sense,
the book is; but it is much more. The principles of the author in regard
to surgical dressings infuse it everywhere, but everywhere it is full of
instructive and suggestive ideas, the value of which is intrinsic, and a
clear surplusage to whatever may be the value of the more proper line of
discussion.

The present volume is a consolidation of one On the Treatment of
Fractures, published in 1871, and one On the Treatment of Wounds,
published in 1878 ; a consolidation in which some recasting has taken
place, and the whole completed by the addition of a section giving plain
and practical directions how to carry out the method which the author
advocates. Its form is what its title would lead one to expect, but it is
systematic and loses nothing by its colloquial style. It opens with a
chapter on the general analogy between wounds of the soft and those of
the hard tissues — wounds and fractures, as the author puts it. In this,
illustrations of the treatment of simple, compound, and complicated
fractures are set side by side with illustrations of the treatment of con-
tusions, simple incised wounds, gunshot and splinter wounds, and the re-
moval of benign and inflamed tumours. The course and issue of these
cases are compared in order to show their analogies. Here, at once, Ave
come upon some of those side-lights referred to, which help to explain
Mr. Gamgee's success as a surgeon. Attention to details is commended,
not in a perfunctory, but apparently in a very sincere way. The injunc-
tions in regard to the application and removal of adhesive plasters, for
example, though by no means novel, somehow give the impression that
the author means them, and that it would not be safe for a dresser in his
hospital to do what we have seen done elsewhere, viz., put a sticking
plaster dressing for fractured clavicle over a very hairy chest, and after-
ward rip it off as if the patient's skin had no more feeling than that of a
hair trunk. And though it is not a discovery of Mr. Gamgee that patient
attention and gentleness are not only conducive to the comfort of the
patient, but also to the success of the surgeon, it is a truth that might be
more widely known and practised upon than it is.

The second chapter treats of the arrest of hemorrhage. Many ligatures
are not commended, but only the fewest number possible, together with
torsion, pinching, and the use of styptic colloid, dry compression and
position. Acupressure is recommended for suitable cases, and Mr. Bryant's
experience with torsion — " Up to 1874, 200 consecutive cases of amputa-
tion of the leg, thigh, arm, and forearm, in which all the arteries were
twisted (110 of them having been of the femoral artery), and no case of
secondary hemorrhage" — is cited in favour of this method. Nevertheless,
it does not appear that Mr. Gamgee has acquired confidence enough in it
to adopt it for closing large arteries.

The third lecture is on sprains, and presents the merits of immobiliza-
tion, compression, and position in their treatment.

The fourth, fifth, and sixth lectures are on fractures of various kinds.
In these no principles are laid down different from those of general
acceptation, except that more stress is laid on gentle but firm compression
than is usual ; and the author emphasizes the fact that provisional callus

542

Reviews.

[Oct.

is an accident of and not essential to union of a broken bone. The cases
which illustrate this part of the book show how successfully the author's
principles may be used in cases apparently most unpromising. At the
same time he candidly mentions instances where they did not succeed,
and where other measures for the reunion of obstinate fracture had to be
adopted. In regard to details, we note the author's advice that blebs
forming under dressings should not be opened, but simply included in the
cotton-wool dressing, and left to take care of themselves. Incidentally
we are told that Mr. Gamgee relies, for the treatment of delirium tremens,
upon twenty-grain doses of bromide of potassium and forty-drop doses of
tincture of digitalis, repeated as frequently as necessary and as permitted
by the general strength. Antimony, in doses of half a grain to a grain
every three or four hours, he thinks also very valuable. He is opposed
to the plan of treating fractures with much swelling by waiting till this
has declined before applying an apparatus. Here he thinks his principle
of moderate compression is peculiarly indicated.

We have used the word " moderate" just now in order to prevent the
possibility of a misunderstanding which it seems there have been people
stupid enough to entertain. For Mr. Gamgee has to stoop to answer a
reviewer, who sagely remarked, a propos of this, that he would " shrink
from applying powerful constriction to an entire limb in which any con-
siderable amount of true inflammatory swelling was taking place." This
of one who says : —

"Pad the whole limb evenly, immobilize with accurately fitting moulds, apply
these soft bandages, with lightness at each turn, and rely for firmness on equally
distributed pressure and repeated intersecting spirals. Pay especial attention to
physiological position, and hold pain in reverential awe. Never look upon pain
as a sentimental evil, but as an expression of organic mischief. Patients with
fractures when properly treated are in comfort, and if they are not it is your
duty to find out the cause and remedy it."

Mr. Gamgee justly exclaims against the much more real dangers of the
ordinary splints and other apparatus, those heavy, ungainly, hot, and
painful loads with which many patients are burdened.

In the chapter which treats of compound fractures, the same method,
comprising cotton padding, regulated compression, and a moulded appa-
ratus, is recommended, and some astonishing cases are cited to prove its
efficiency. The same may be said of amputation after crushing injuries.
In which connection a warning against being too ready to amputate is
given, and the famous case of Percival Pott, who came near having his
leg cut off unnecessarily, is cited.

* The seventh lecture treats of wounds into joints, in regard to which the
first caution is one, by no means uncalled for, against excessive diagnostic
inquisitiveness. The treatment recommended is closure — by sutures if
necessary — dry dressing, moderate compression, and immobilization.
Where inflammatory action has already begun the introduction of a
drainage-tube may be required.

In the eighth lecture there is some explanation and illustration of the
philosophy of the method Mr. Gamgee advocates. Accurate and im-
movable coaptation of divided surfaces is said to be the essential thing ;
infrequent dressing is but a corollary of the principle of absolute rest.
That these are not novel truths is shown by references to older writers
and surgeons, who, without formulating their views just as Mr. Gamgee
does his, were guided in their practice by the same principles.

1883.] Gam&ee, Treatment of Wounds and Fractures.

543

In the ninth lecture the general applicability of dry and absorbent
dressings is dwelt upon, and the unwise use of poultices ancf water dress-
ings is deprecated.

The tenth lecture is devoted to drainage and mode of suspension.
Drainage-tubes, the author reminds us, were suggested to Chassaignac by
observing the way farmers drain boggy land with earthenware pipes. He
gives excellent instructions as to the way they should be used, and remarks
on the assistance they may receive from position. Suspension, as a means
of securing the advantage of position and of allowing motion without
disturbance of fragments or cut surfaces, is described and illustrated with
some very good cuts.

The eleventh lecture treats of wounds of the scalp and skull. In regard
to these the advice given is to avoid interference as much as possible. A
number of apparently desperate cases of depressed fracture are cited
where recovery followed upon the use of dry dressings with ice. Mr.
Gamgee inclines to the opinion, which he begs may be accepted " with
much reservation," that in compound and depressed fracture of the skull,
without brain symptoms, the trephine should not, as a rule, be used. If
constitutional or local symptoms warrant the belief that blood or pus is
collected under the meninges, or that a fragment of bone is pressing upon
the seat of injury, he thinks the use of the trephine " may be justifiable."
He appropriately remarks that on this question some of the greatest sur-
geons have been arrayed on opposite sides ; and adds that the subject is
one in which disinclination to dogmatize grows with experience. He
quotes and cites a large number of surgeons to show the superiority of
non-interference, and calls attention to the singular fact, that while the
English and Americans are quite free with the use of the trephine, French,
German and Italian surgeons rarely employ it. He then quotes a number
of modern English writers and one American — Dr. Stimson (with his
name misspelled) — in favour of the trephine. In conclusion, after a rather
ambiguous statement of his own opinion, he gives three cases where he
used the trephine in which the results were all that the most ardent advo-
cate of interference could desire.

This subject is, as Mr. Gamgee says, one in regard to which doctors
disagree. A little over a year ago it was brought before the American
Surgical Association, meeting in Philadelphia (see The Medical JVeivs,
June 10, 1882), by Dr. Moses Gunn, of Chicago, who advocated operative
interference in all recent fractures with depression, whether simple or
compound, even though entirely without symptoms of compression. The
majority of those who discussed this proposition expressed similar opin-
ions. There were, however, three very important opponents of these
views. Dr. Hunter McGuire, of Richmond, thought that if a fracture is
simple, and the amount of depression not enough to bring on symptoms
of compression, the surgeon had better let it alone, and trust to the brain
accommodating itself to the change. Dr. R. A. Kinloch, of Charleston,
shared this view ; and Dr. S. W. Gross, of Philadelphia, advocated non-
interference in cases of moderate depression, except where there were
evidences of irritation pointing to a depression of the internal table, of the
skull. In regard to one's attitude toward this question, very much ap-
pears to depend upon the temperament of each surgeon.

The twelfth and last lecture of Mr. Gamgee's book is occupied with a
discussion of what has come to be called "antiseptic" surgery. The claim
that its success depends upon its adaptation to the so-called germ theory

544

Reviews.

[Oct.

of Pasteur, is combated. The origin of this adaptation is traced back to
Declat, six years before Lister's first essay. Its results are shown to be
no better than those of various other methods which take no note of
" germs." The key-note of Mr. Gamgee's views is found in the para-
graph : " Life and putrefaction are not correlative, but antagonistic ; and
in proportion as the surgeon utilizes and economizes the attributes of life,
he will find himself independent of those changes which are inherent to
decaying organic matter ; whether it be in bagging wounds or boggy
lands. Life is the great antiseptic" (italics ours). He has no fear of
" impalpable and implacable germs," and he politely ridicules the lan-
guage in which those who do fear them warn against the slightest failure
to carry out all the details of " Listerism." In doing this he does not
detract from the value of antiseptics ; it is the formulated association of these
with the " germ theory" which he deprecates. In all he is guilty of no
discourtesy to Mr. Lister, in whom he recognizes a single-minded enthu-
siasm, combined with rare accomplishments as a chemist, a microscopist,
a naturalist, and a surgeon.

The concluding part of the book before us is occupied by a chapter and
an " addendum," giving practical directions in regard to the materials
and apparatus recommended by Mr. Gamgee, and how to use them. Into
the details of this we have not time to enter ; but we may refer to it as
an indispensable and exceedingly valuable addition to what has gone
before it.

The book has also an index which adds to its value.

From what has been said, it will be seen that we have here a book of
unusual interest. As the mere exponent of the views of an able and ex-
perienced surgeon, it wrould be entitled to respectful attention, but it has
a still better claim in its intrinsic value. It is not only eminently in-
structive, but also suggestive. Its style is clear and logical, its spirit
genial and attractive. Whether discussing a mooted point, or speaking
of the consideration which every surgeon should have for his patient's
feelings, there is constantly revealed the warm, kind heart of a polite and
humane man. While writing to establish what he believes to be a great
principle, the author has not despised bestowing scrupulous attention upon
details often erroneously regarded as of minor importance. Many in-
stances of this could be cited, of matters often overlooked or neglected ; but
we will only refer to his suggestions as to the use of collodion for obtain-
ing pressure, which has a larger field of usefulness than is often suspected ;
as to the importance of having slings for the forearm so arranged as to
keep the elbow at an acute angle — the hand higher than the elbow —
which is constantly violated ; as to the use of adhesive straps in certain
injuries, to control hemorrhage ; as to inquiry for and correcting of con-
stipation ; as to the significance of the appearance of discharges ; as to
keeping temperature charts out of sight of patients, so that they may not
have the alarm which changes might cause ; as to personal supervision
after operations ; as to the value of temporary digital compression to con-
trol pain and allay inflammation. These and the way they are put are
features of the book which add to the feeling of respect for the author
that of regard for the man. It is a privilege to read such a book, and a
pleasure to commend it to others. C. W. D.

1883.]

Harrison, Observations on Lithotomy.

545

Art. XXX Handbook of Electro-Therapeutics. By Dr. Wilheim

Erb, Professor in the University of Leipzig. Translated by L. Pltzel,
M.D. With thirty-nine wood-cuts. 8vo. 366 pases. New York: Wm.
Wood & Co., 1883.

Works on electro-therapeutics are becoming so numerous that it is diffi-
cult to keep pace with them. Professor Erb has long been known as a
scientific worker in electro-therapy ; and, in addition, has a reputation
in general neurology that is almost world-wide, so that any work from
his pen is sure to have merit. In the physical and pbysiological introduc-
tion, and in the applications of physiology to electro-diagnosis are found
many evidences of the author's ability and originality. It is well known
that to Professor Erb the term " degeneration reaction," and most of our
exact knowledge of this reaction, are due ; and in the present treatise he
carefully describes and expounds this subject both with reference to typi-
cal and atypical cases.

The defects of the book are diffuseness, the recital in detail of too many
cases, and claiming too much for electricity as a therapeutical agent.

Particular attention is given to the technique of electro-therapeutics.
Many cases illustrating unusual beneficial effects of electricity have been
brought together from periodical literature. The book will prove highly
satisfactory to those desiring both a scientific and practical exposition of
electro-therapeutics. C. K. M.

Art. XXXI. — Observations on Lithotomy, Lithotrity, and the Early
Detection of Stone in the Bladder; with a Description of a New
Method of Tapping the Bladder. By Reginald Harrison, F.R.C.S.,
etc. 8vo. pp. 71. London : J. & A. Churchill, 1883.

In a review of Mr. Harrison's " Lectures on the Surgical Disorders of
the Urinary Organs," which we published in January, 1882, we made the
remark that "it is surprising to an American, meeting the names of
Gouley, Otis, Keyes, etc., to miss that of Gross." In contrast to this,
the first thing we observe, on opening the book before us, is that it is dedi-
cated to Professor Gross, with most complimentary and respectful expres-
sions. A short, twelve-line preface follows, and the author plunges at
once in medias res.

Mr. Harrison's observations, he tells us, are founded upon an experience
embracing no less than sixty operations of cutting and crushing. And it
is especially as the result of experience, and of a manifestly careful and
conscientious spirit, that these observations have a value for the surgeon.
The book, indeed, is not like a text-book for students, but like a paper
intended to be read before the author's associates, from which much in-
struction may be gathered, but in which there is nothing of the pedagogic
spirit discoverable. For this reason a review of it ought to be conducted
as one's remarks might be, who was called upon to speak at a meeting
alter such a paper had been read. Such a one might differ from the
No. CLXXII Oct. 1883. 35

546

Reviews.

[Oct.

author as to certain details, but for his essay, as a whole, he could only
entertain a high respect. He might, for example, suggest that a little
more exact knowledge in regard to the technique and merits of supra-
pubic lithotomy would have prevented the author from giving the impres-
sion that an incision through the perineum is a necessary or even an
ordinary part of it, and he might regret that the renal origin and uric
acid nucleus of most calculi should, by implication, seem to be ignored.
But the remarks on the subject of lithotomy and lithotrity in general, he
would acknowledge to be both instructive and suggestive.

More than two-thirds of this book are devoted to the field of lithotrity,
which in Great Britain has so largely superseded lithotomy, and which
has of late received so great an impetus from the adoption of the instru-
ments and method of Prof. Bigelow. In regard to the latter, an ill-con-
cealed allusion is made to the reluctance to recognize its merits on the
part of the most distinguished advocate of the old method of lithotrity in
Great Britain, and the author's own appreciation of them is most une-
quivocally stated.

Mr. Harrison's views in regard to the principles which should guide
the surgeon in the choice of a method of operation — cutting or crushing —
are conservative and judicious. So are his remarks in regard to the
early detection of stone in the bladder.

The " New Method of Tapping the Bladder," mentioned in the title of
this book, consists in thrusting a trochar and canula through the perineum
and prostate gland. A peculiar instrument, specially adapted to the pur-
pose, is described and figured, and the endorsement of Professor S. D.
Gross — which is contained in the sixth edition of his System of Surgery —
is given.

As remarked at the beginning of our review, this book is not a text-
book, and so is not suited to the needs of the average student, but for the
surgeon it is just the thing. In manner it is mosfpleasing — in matter it
is most suggestive. C. W. D.

Art. XXXII. — Anatomy, Descriptive and Surgical. By Hexry Gray,
F.R.S., with the collaboration of T. Holmes, M.A., H. V. Carter,
M.D., and T. Pickering Pick. A new American, from the tenth
English edition. To which is added Landmarks, Medical and Surgical,
by Luther Holden, F.R.C.S., with additions by TV. W. Keex, M.D.
8vo. pp. xxxii., 1023. Philadelphia : Henry C. Lea's Son & Co., 1883.

But little need be said of this book save that it is the tenth edition.
Saying this only we say very much, for few books have such a vigorous
life. The present edition has undergone careful revision, some of the sec-
tions on microscopical anatomy have been altered or entirely rewritten,
and several of the illustrations have been bettered, and a few additional
ones added.

Of all the many text-books on anatomy, this has been ever since its
issue in 1858 facile princeps, and we see no reason why it should lose
its rank. W. W. K.

1883.]

547

QUARTERLY SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES

IN THE

MEDICAL SCIENCES.

ANATOMY AND PHYSIOLOGY.

Primary Radicles of the Lymphatic System.

A method for measuring in a satisfactory manner the primary radicles of the
lymphatic system has been vainly sought for during the past three centuries.
M. Sappey has recently read a paper before the Academic des Sciences, in
which he states that he has discovered a method by which they can be clearly
seen. His method demonstrates that the vessels of which this system is composed
originate in the tissue of the organs by minute capillaries, the calibre of which
does not exceed 1 mmm. (^shu'V inch), that these capillaries freely inosculate,
and that at the level of their communications there exist very minute starred en-
largements or swellings (lacunae) . A network of these minute capillaries and
lacuna? represents the primary radicles of the lymphatic system. The chief cause
of the failure to demonstrate these radicles heretofore is due to their perfect trans-
parency. M. Sappey has succeeded in giving the capillaries and lacuna? a pale
yellow colour, which enabled him to demonstrate them. This was done by filling
these cavities with a quantity of the lowest order of vegetations of the lowest
order of cryptogams. These microphytes, generally recognized as microbes, are
sharply outlined. They differ markedly both in outline and configuration, but
may be classed under two principal groups, the one having the form of rounded
and brilliant cells, and belonging to the micrococcus family, the others elongated
and cylindrical, belonging to the bacteria family.

If the microbes proliferate rapidly in the plasma of lymph, they grow with
equal rapidity and abundance in blood serum, and if their presence is necessary
for a demonstration, it is important that they should appear in the lymphatic
capillaries only, and not in the blood capillaries. In order to prevent this acci-
dent he injected the blood capillaries with an acidulated liquid, sufficiently abun-
dant to carry away their contents ; in other words, he substituted for the blood
plasma, a favourable medium for the development of the microphytes, a solution
in which they cannot proliferate, with the result that no vestige of them could be
found in the blood capillaries. The primary radicles of the lymphatic system,
filled, on the contrary, with coloured cells, were alone seen in the field of the
microscope, and so clearly, in fact, that they could be studied in their entirety,
and as to their smaller details, and most minute variations.

548

Progress of the Medical Sciences.

[Oct.

Is there a communication between the primary lymphatic radicles and those of
the blood capillaries V At the beginning of his studies on the absorbent vessels,
M. Sappey believed it, and developed this opinion in his works. In admitting this
communication and supporting it, he acted on general considerations deduced from
normal and pathological anatomy ; he had no observed fact to support this view.
But he now declares that by a certain procedure the closest connections of the
lymph and blood capillaries can be seen. The latter are of so large a calibre
as compared with the former that they may be likened to the trunks of trees,
and the lymph capillaries to climbing plants embracing all parts of the tree, the
lacuna? representing the leaves of the climbing plants. When a preparation is
examined at the moment of immersion in the reagent for bringing out the lacunas,
at first the blood capillary only is seen. Then, under the influence of the reagent,
lacunas appear here and there : the blood capillary gradually disappears as the
lacunae become more and more visible. During this successive appearance and
disappearance of the lymph and blood capillaries, there is a moment when the
observer can distinguish, at the same time, the two kinds of vessels, and in the
best conditions for observing their communications if they exist. But even in
these favourable conditions it has so far been impossible for him to see the slight-
est communication between them. From these new and concise facts, and apart
from all deductions, he concludes that there is no reason for admitting an inter-
communication ; the lymphatic vessels are hermetically sealed. Blood plasma pen-
etrates the primary radicles by simple transudation or by capillarity, by undergo-
ing only slight modifications.

The histological characters of the primary radicles differ according as one con-
siders the network of the lacunae and minute capillaries or the subjacent net-
work. The superficial network is composed of an ensemble of cavities, the
walls of which have, apparently, no endothelial cells. Nitrate of silver, which
acts so readily in bringing out these cells in other parts of the circulatory appa-
ratus, has no effect on the minute capillaries and the lacunae. Their walls are
formed simply of an amorphous (structureless?) membrane. The collecting net-
work under the preceding has a more complex texture. On the vessels compos-
ing it are seen endothelial cells easily shown by nitrate of silver. These cells
form a continuous sheath which lines the internal surface of the proper or struc-
tureless membrane. The wall of the sub-papillas vessels or collectors is composed,
then, of two layers. As to the existence of a muscular structure in these two
layers, M. Sappey cannot speak with certainty. He has not seen the slightest
trace of such structure, and from a uniform failure to see it after repeated trials
he thinks that he is justified in saying that no such structure exists at the origin
of the lymphatic vessels nor for some distance from their origin. — V Union 3J^d.,
June 23, 1883.

A New Centre of Vision in the Human Eye.

For a long time M. Delbceuf has observed that sensibility for light is greater
at the periphery than at the centre of the retina. If one uses a vacillating flame,
such as given by a candle, it will be seen that, though there may be but little
light on the book or paper immediately before the eye, there is a dazzling, some-
times almost insupportable glare, on the other white papers on the table, seen by
indirect vision. Or the reader may turn his back to the window, holding in the
hand a white paper almost horizontally, and a slightly movable shadow is seen
projected on the paper, the movements of the shadow being more visible if the eyes
are directed to the top or the sides.

After a series of experiments on this subject j\L Delboeuf draws the following
conclusions : —

1883.]

Anatomy and Physiology.

549

1. The macula lutea, of which the visual acuity is greater than that of any
other part of the retina, has less sensibility for the differences of brightness.

2. The part of the retina most sensible to luminous differences is a line situated
in the vertical meridian, and commencing about 30° from the macula lutea, and
extending, in most of the eyes examined, as far as 60° and over, from it.

3. Beyond this line the sensibility goes on decreasing, but in such a manner
that the maximum lines of each meridian enclose the macula lutea, remaining
within the limits of 30°-20° of it.

4. The sensibility is, generally speaking, greater in the internal and superior
demi-meridians.

5. Save personal differences, the two eyes appear to be organized symmetri-
cally as far as this special sensibility is concerned. — Revue Scientijique, August
11, 1883.

Kymographic Measurements in Men.

Of all the methods, says Prof. E. Albert, of Vienna, which have hitherto
been employed for determining the blood-pressure and obtaining true traces, the
registering kymographion of Ludwig is the best and most productive of true
results. Heretofore, experiments with this instrument have only been made on
animals. Dr. Albert has recently, however, recorded cases in which the experi-
ment was made on the human subject, before amputation of a limb. A disinfected
canula was bound into a vessel. All the experiments were made in cases in
which the thigh or the leg had to be amputated. The experiment only lasted
a few minutes in most of the cases. The vessel chosen was the anterior tibial
artery, on account of the ease with which it could be reached. The subject was
slightly narcotized, the instrument applied, and the anaesthetic removed while
the tracing was taken. In one case there was an abnormality of the heart; the
tracings in this case had a special value.

The tracings taken by Prof. Albert oppose the assertions of Schapiro and
Thomayer that the blood-pressure is higher in the erect than in the sitting pos-
ture. The blood-pressure was regularly increased when the epigastrium of the
patient was raised. It is possible that when the upper part of the body was
raised up the abdominal viscera were pressed on, and a portion of their blood
sent into the right heart, by which the pressure was raised. In the erect position
it may be possible, on the other hand, that so much blood is collected in the
veins of the abdominal viscera and upper extremity that the aortic pressure is
lowered. The blood-pressure during the passive upright position of the upper
part of the body was between 10 and 20 mm. of mercury, and remained so as
long as the subject was left in that position. Even a very slight elevation of
the body gave a different result. In one case the pressure was raised when the
subject coughed, which explains why the act of coughing may produce haemop-
tysis. It may be mentioned, also, that morphine not only allayed the cough
irritation, but lowered the blood-pressure. In two cases in which the other
lower extremity was enveloped by an Esmarch's bandage during the experiment
the blood-pressure was raised about 15 mm. As a rule there was but slight varia-
tion during the respiratory act ; only in a few cases was there marked indication
of the respiratory rhythm. This may be partially explained by the fact that- the
breathing of the patient was very quiet. This regular blood-pressure under the
anaesthetic indicates that the present methods of producing narcosis are approach-
ing perfection. Three plates are given, indicating some of the results obtained.
The mean blood-pressure in six cases was between 100 and 160 mm. — Medizin.
Jahrbiicher, 1883, Hft. ii.

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Physiology of the Bladder and Rectum.

The following are the physiological conclusions drawn by Mr. F. Le Gros
Clark at the close of an interesting paper on this subject : —

1. The muscular coat of the bladder acts under the government of the will,
but is also subject to reflex influence.

2. The abdominal muscles take no necessary part in the expulsion of the
urine.

3. In early life the action of the bladder is chiefly reflex, but is gradually ren-
dered voluntary by education and habit.

4. The retaining power of the bladder is due (a) in great measure to the
hydrostatic law, in accordance with which the egress of fluid from a reservoir
through a small tube is determined ; (&) to the elasticity and (?) muscularity of
the urethra ; (c) to its compression, whilst under the arch of the pubes, by the
compressor urethra? muscle.

5. The annular fibres around the neck of the bladder have not a sphincter
action.

6. Incontinence or retention of urine may be referred to excessive or deficient
sensitiveness of bladder, ill-regulated control, atony, mechanical obstruction.
When violence is inflicted on the nerve-centres — either brain or spinal cord — the
bladder may be rendered partially or wholly incapable of expelling its contents.
In lesion of the brain this incapacity is proportioned to the profundity of the
coma, and due to insensibility and suspension of voluntary power. In compres-
sion of the cord the cause is the same, but operates by interruption of the afferent
and efferent currents ; and the reflex energy of the cord is also impaired.

7. The rectum is guarded at its outlet by two sphincter muscles, one cutaneous
and chiefly voluntary, the other intestinal and spinal-reflex. In compression of
the brain the former is almost or entirely disabled; in compression of the cord
the power of the latter is likewise impaired.

8. Where an appeal is made, through common sensation, to the nerve-centres,
it is not consistent with our physiological knowledge to exclude volition from
participating in the origination of the motor force which is evoked by that appeal.

In the preceding pages, the nature of my subject has compelled me to assume
as probable some things which do not admit of demonstrative proof ; and where
this is the case, I have expressed myself accordingly. But if my views are such
as to satisfy physiological criticism, I may venture to claim for them the further
recommendation that they afford a reasonable explanation of some of the other-
wise obscure pathological phenomena presented by the excretory urinary organs.
— Journ. of Anat. and Physiol., July, 1883.

MATERIA MEDICA AND THERAPEUTICS.

Physiological Action of Barium Chloride.

Drs. Sidney Ringer and Harrington Saixsbury have recently pub-
lished the results of their experiments as to the action of barium chloride on the
animal organism. The question to be decided was whether barium acts directly
on the tissues in which it manifests itself, or indirectly on these through the me-
dium of the nerves ?

They briefly recapitulate the steps in their argument as follows : —

1883.]

Materia Medica and Therapeutics.

551

1. We have the experiments of Boehm showing the systolic heart, the retarded
pulse-rate, and the heightened blood-pressure, resulting from barium chloride
action.

2. We find that the systolic heart and the retardation occur equally when the
centres of reflex control are destroyed.

3. We find that the local application of the salt, in diluted solution, to the
heart in situ, produces local spasm at the point of application ; and also that the
excised heart is arrested in full systole by the drug.

4. We find that the vessels freed from central nervous control respond to the
direct action of the salt.

5. We find that we are unable to influence the calibre of the vessels through
the nerves apart from direct local action.

We here see that the action on the heart is a guide to the action on the arte-
rioles, or vice versa, and this we should feel inclined to expect : since, on tissues
resembling one another, we should look for a resemblance of effects. This question
will be gone into more fully in a paper shortly to be published, on the digitalis
group generally, in respect of which the experiments were conducted after the
same methods described here.

To the marked resemblance in action between barium chloride and digitalis we
need scarcely draw further attention. Boehm pointed it out, and it is sufficiently
manifest. But of the alternative which he gave us for barium chloride action,
viz., either action on the whole sympathetic system, or on unstriped muscular
tissue generally and specifically, we must choose the latter.

The . therapeutic value of barium chloride yet remains to be determined; the
drug is clearly a very powerful one, and in this respect is widely separated from
its chemical analogue calcium chloride. As to the directions in which clinical
observation should extend, we get a clear indication from the digitalis-like action
of the drug. — British Med. Journ., August 11, 1883.

Action of Saline Cathartics.
Mr. Matthew Hay, of Edinburgh, at the close of a long and exhaustive
article on this subject, draws the following conclusions : —

1. A saline purgative always excites more or less secretion from the alimentary .
canal, depending on the amount of the salt and the strength of its solution, and
varying with the nature of the salt.

2. The excito-secretory action of the salt is probably due to the bitterness as
well as to the irritant and specific properties of the salt, and not to osmosis.

3. The low diffusibility of the salt impedes the absorption of the secreted
fluid.

4. Between stimulated secretion on the one hand, and impeded absorption on
the other, there is an accumulation of fluid in the canal.

5. The accumulated fluid, partly from ordinary dynamical laws, partly from a
gentle stimulation of. the peristaltic movements excited by distension, reaches
the rectum and produces purgation.

6. Purgation will not ensue if water be withheld from the diet for one or two
days previous to the administration of the salt in a concentrated form.

7. The absence of purgation is not due to the want of water in the alimentary
canal, but to its deficiency in the blood.

8. Under ordinary conditions, with an unrestricted supply of water, the maxi-
mum amount of fluid accumulated within the canal corresponds very nearly to the
quantity of water required to form a 5 or 6 per cent, solution of the amount of
salt administered.

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[Oct.

9. If, therefore, a solution of this strength be given, it does not increase in
bulk.

10. If a solution of greater strength be administered, it rapidly increases in
volume until the maximum is attained. This it accomplishes in the case of a
20 per cent, solution in from one to one and a half hours.

11. After the maximum has been reached, the fluid begins gradually and
slowly to diminish in quantity.

12. Cceteris paribus, the weaker, or in other words, the more voluminous the
solution of the salt administered is, the more quickly is the maximum within the
canal reached ; and accordingly purgation follows with greater rapidity.

13. Unless the solution of the salt is more concentrated than 10 percent, ir
excites little or no secretion in the stomach.

14. The salt is absorbed with extreme slowness by the stomach of the cat.

15. The salt excites an active secretion in the intestines, and probably for the
most part in the small intestine, all portions of this viscus being capable of yield-
ing the secretion in almost equal quantities.

16. The bile and pancreatic juice participate but very little in the secretion.

17. The secretion is probably a true succus entericus, resembling the secretion
obtained by Moreau after division of the mesenteric nerves.

18. The secretion is promoted by local irritation of the intestine, as by liga-
tures, but only in the immediate vicinity of the irritation.

19. Absorption by the intestine generally is reflexly stimulated by such irrita-
tion (the effect of numerous ligatures applied at points remote from the seat
of the injected salt being to diminish the amount of purgative iiuid by accelerated
absorption).

20. If the salt solution be injected directly into the small intestine, the stronger
within certain limits the solution is, the greater will be the accumulation of iluid
within the intestine.

21. This difference is not observed when the salt is administered per orem, as
the strong solution becomes diluted in the stomach and duodenum before passing
into the intestine generally.

22. The difference is due to the local action of the salt on the mucous mem-
brane, and probably more to an impeded absorption than to a stimulated
secretion.

23. When the salt is administered in the usual manner, it appears, in the case
of the sulphate of magnesia and sulphate of soda, to become split up in the small
intestine, the acid being more rapidly absorbed than the base.

24. A portion of the absorbed acid shortly afterwards returns to the intestines.

25. After the maximum of excretion of the acid has been reached, the salt
begins very slowly and gradually to disappear by absorption, which is checked
only by the occurrence of purgation.

26. During the alternations of absorption and secretion of the acid, it is the
salt left within the intestine which excites secretion, the absorbed and excreted
acid exerting no such action whilst in the blood, or during the process of its
excretion, as Headland believed.

27. The salt does not purge when injected into the blood, and excites no intes-
tinal secretion.

28. Nor does it purge, when injected subcutaneously, unless in virtue of its
causing local irritation of the abdominal subcutaneous tissue, which acts reflexly
on the intestines, dilating their bloodvessels, and perhaps stimulating their mus-
cular movements.

29. The sulphate of soda exhibits no poisonous action when injected into the
circulation.

1883.]

Materia Medica and Therapeutics.

553

30. The sulphate of magnesia is, on the other hand, powerfully -toxic when so
injected, paralyzing first the respiration and afterwards the heart, and abolishing
sensation or paralyzing the sensory-motor reflex centres.

31. Both salts, when administered in the usual manner, produce a gradual but
well-marked increase in the tension of the pulse.

32. According as the sah>solution within the intestine increases in amount,
there occurs a corresponding diminution of the fluids of the blood.

33. The blood recoups itself in a short time by absorbing from the tissues a
nearly equal quantity of their fluids.

34. The salt, after some hours, causes diuresis, and with it a second concen-
tration of the blood, which continues so long as the diuresis is active.

35. As the intestinal secretion excited by the salt contains a very small pro-
portion of organic matter as compared with the inorganic matter, the purgative
removes more of the latter than the former from the blood. In certain cases a
large quantity of the salts of the blood is thus evacuated.

36. The amount of the normal constituents of the urine is not affected by the
salt.

3 7. After the administration of sulphate of magnesia much more of the acid
than of the base is excreted in the urine.

38. The salt has no specific action in lowering the internal temperature of the
body, or has it only to a very small extent.

39. It reduces, however, the absolute amount of heat in the body. — Journal
of An at. and Physiol., July, 1883.

Action of Piperidin.

Fliess, in an article in a recent number of the Archiv fiir Anat. und Physiol.,
gives the results of some researches he has made on this substance. He finds
that if a dose of piperidin be subcutaneously injected into a frog, after a short
period of unrest the animal remains remarkably quiet, and no longer moves
when the foot is pinched, and that this is not due to lesion of the muscles or to
paralysis of the motor nerves is shown by the vigorous movements that are made
if the sciatic nerve be stimulated by an induced current. Paralysis of the sen-
sory nerves must, therefore, be the cause of the lack of response of the animal
to sensory stimuli, and the question arises whether it is the nerve or the centre
that is paralyzed. The loss of reflex excitability takes place about ten or twelve
minutes after the injection of one milligramme of piperidin, and is so complete
that even its contact with the eye fails to elicit any response. Recovery of the
sensibility occurs at the expiration of twenty-four hours. It has been rendered
probable by Kronecker's and Sterling's experiments that a single shock is insuf-
ficient to excite a reflex action, and that at least two are required, which must
be separated by a short interval only. In his experiments with piperidin, how-
ever, Fliess found that the time which elapsed between two shocks in order that
a reflex movement should be induced was not altered, but only that the shocks
must be much stronger. Hence he arrives at the conclusion that it is not the
centre which is acted on by the piperidin, but the conducting agent — the nerve.
The paralysis of the sensory nerves only occurred in those parts of the body to
which the blood impregnated with piperidin was distributed ; in any part of it
protected from the action of such blood the sensory fibres retained their function.
Further experiments demonstrated that the part of the sensory nerves on which
piperidin acts is their peripheric termination. All the experiments proved that
neither the muscles nor the motor nerves were in any way affected.

Other results observed after the subcutaneous injection of one milligramme of

554

Progress of the Medical Sciences.

[Oct.

piperidin were that the frequency of respiration fell to one-half the normal
amount — that is, from 60 to 36 and 30 per minute. Large doses led to the Stokes'
phenomenon, respiration being interrupted for two or four minutes, after which
the frog made from three to four respirations. In regard to the cardiac beats,
their number similarly fell to about two-thirds of the normal, from 54 to 34 per
minute.

Fliess further made some observations on the action of piperidin on warm-
blooded animals, but did not find that its effects, in the rabbit at least, were
nearly so well marked, even though fatal doses were administered, and this he
attributes in part to the circumstance that piperidin oxidizes with extraordinary
rapidity in the body. The frequency of respiration was considerably reduced,
the number falling from 200 to 48 per minute, whilst the cardiac beats rose from
220 to 340 per minute, so that it would appear that the vagal centre was para-
lyzed. The pupil became widely dilated, and the heart, when death occurred,
was arrested in systole. Fliess appends the results of some other experiments he
made on acetyl piperidin, benzyl piperidin, and methyl piperidin ; also of some
experiments on coniin. — Lancet, July 28, 1883.

Iodoform.

Dr. Hofmakl, at the conclusion of a paper on the surgical uses of iodoform,
draws the following conclusions : —

1. Iodoform is an excellent disinfectant, and, as a rule, is a painless application
to wounds.

2. On account of its slight solubility, it is of little value in complicated
wounds of cavities.

3. It does not prevent the occasional outbreak of erysipelas.

4. It is not a specific against scrofulous or tuberculous processes, and develops
its healing properties most notably in ulcerous processes.

5. By keeping wounds fresh and clean, it furthers granulation, though it has but
little influence on the final cicatrization of the wound.

6. Very thin layers of powdered iodoform do not hinder union by first in-
tention.

7. In pharyngeal and laryngeal diphtheria of children, iodoform does not give
much better results than other antiseptics.

8. In wounds and ulcers of the mouth, rectum, and vagina, as well as in open,
easily accessible wounds in the cavities of bones, iodoform, in the form of a 30
to 50 per cent, iodoform gauze, is an excellent antiseptic dressing.

9. Parenchymatous injections of iodoform generally cause a great deal of pain,
and it cannot be said that they give very excellent results in fungous diseases of
joints and glandular swellings.

10. Iodoform ointments and plasters are often of good service in parenchy-
matous goitres and chronic swellings of glands, joints, and tendons.

11. Iodoform in large quantities is undoubtedly dangerous, and is more pro-
ductive of good results, and less hurtful in small doses.

12. Childhood is not a contraindication for the use of iodoform.

13. The preliminary cleansing of fresh wounds with weak carbolized water
before using the iodoform dressing is of no advantage so far as Hofmakl's ex-
perience goes.

14. The healing of scrofulous and tuberculous sores by iodoform does not
prevent their return.

15. Iodoform is an excellent means for the thorough removal of disagreeable
odours of neoplasm which do not admit of operation.

1883.]

Materia Medica and Therapeutics.

555

16. The occasional syringing of suppurating cavities with small quantities of
iodoform emulsion will often have a favourable action on the quality and quantity
of the pus.

1 7- The introduction of iodoform bougies into the urethra and bladder will
often alleviate pain, as also in vesical tenesmus and suppurative conditions of
the bladder, and will exert a favourable influence on those conditions of the
urine in which rapid decomposition takes place.

18. The application of iodoform bougies to long fistulas of the soft parts is
more hurtful than useful, as the fistula? are only stopped up, and the products of
decomposition are not discharged. Equally unwise is the filling up of the mouth
of a fistula with dry powdered iodoform. — Medizin. Jahrbiicker, 1883, Hft. ii.

Ancesthetic Action of a Mixture of Air and Chloroform.

M. Paul Bekt has recently communicated the results of further experiments
on this subject to the Academie des Sciences. His experiments were made with
an apparatus composed of two gasometers, acting alternately. A dog was made
to respire a mixture of the proportion of 3j of chloroform, vapourized in 30
gallons of air. The animal remained sensible during the whole time, which was
prolonged in one case for 9^- hours. The rectal temperature fell to 98° Fahr.
With a mixture of £jss of chloroform, vapourized in 30 gallons of air, death
took place after about seven hours' inhalation, with a temperature of 87.8° Fahr.
Sensibility persisted during the whole time, but was much feebler when the
animal became cold. With gij in 30 gallons of air, insensibility of the skin and
cornea was obtained, but it came on slowly after some agitation. Death took
place in about 6 hours, the temperature having fallen to 86° Fahr. With ^ijss
to 30, insensibility appeared in a few minutes. • The sleep was absolutely calm,
and death took place in about 2 or 2^ hours, without convulsions. The tempe-
rature was 91.4° Fahr. With a mixture of 3iij— 30, insensibility was more
rapid with no reaction ; death in \\ hour, temperature 95°. With a mixture of
giijss and £iv to 30, death occurred in forty-five minutes, temperature 100.4°.
With 3ivss and gv to 30, death occurred in 30 minutes ; and in a few minutes
when a mixture of ^vijss to 30 was used. Tracheotomy was performed in every
case before the experiment. The chloroform was pure. M. Bert calls attention
to the following facts : 1 . Whether death comes on slowly or quickly, the heart
always Continued to beat after respiration had ceased ; there was never any car-
diac dyspnoea. 2. There was no chloroform in the urine except after anaesthesia
of several hours. 3. With very small doses, one may cause an enormous quan-
tity of chloroform to circulate in the lungs, with no other objective phenomenon
than a fall of temperature. 4. With slightly increased doses one may cause slow
death with great lowering of temperature ; but sensibility persists. In these
doses chloroform acts only on the nutritive functions, probably by benumbing the
anatomical elements, just as beer acts according to the experiments of Claude
Bernard. 5. In larger doses, when insensibility is clearly established, death is
always the consequence of continued respiration of the chloroform mixture.
The larger the proportion of chloroform, the more rapid is death, and the less
the fall of temperature. The experiments of M. Bert show that the method of
administering chloroform is best and least dangerous by which the patient is
quickly anaesthetized by a large quantity, and then kept under the anaesthetic by
a much smaller amount. — L' Union Mgd., July 7, 1883.

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Value of Hyoscyamine in Psychiatric Practice.

M. Gnauk has recently contributed a paper on this subject in which he speaks
in high terms of hyoscyamine as an efficient remedy in psychiatric practice.
Amorphous hyoscyamine contains a large amount of hyoscine. Hyoscine is
hypnotic in doses of gr. TI3 to F'5, or^, subeutaneously, is hypnotic, but very toxic
even in these small doses. Purified, colourless hyoscyamine is not constant in
its effects, is uncertain, and sometimes toxic in doses of gr. 1^. Crystallized,
pure white hyoscyamine, in doses of gr. T^ff to subeutaneously, is more satis-
factory, because, when completely pure, it can be given in quantities of known
strength as a safe and efficient hypnotic, producing but little toxic effect, and,
on account of its solubility, answers admirably for hypodermic use. Its most
important action lies in the fact that it is hypnotic without being markedly toxic.
It acts very rapidly and efficiently on insane patients as well as on others. Ten
minutes after its administration, the pulse rises from 76 to 120 or 130, and
then beats regularly. The narcotism may be complete, or simply manifested by
lassitude, and the patient is calm though not analgesic. The sleep produced is
long, lasting during the whole night. The best form for hypodermic administra-
tion is distilled water f^vss, cherry laurel water f J^ijss, hyoscyamine grs. ivss ;
gr. ^ of hyoscyamine equals grs. xxx of chloral, gr. -f5 of morphine, and grs. xlv
of bromide of potassium. Gnauk has seen gr. f5 of hyoscyamine act as efficiently
in rebellious cases as gr. 1§ of morphine. In agitated cases gr. ^ should be
used at once; with more tranquil cases one may commence with gr. T'?, in-
creasing, if necessary, to gr. ^ or ss. The prodromata of intoxication are increase
of delirium, special hallucinations (such as seeing large animals), and great dila-
tation of the pupil. When the pupil is not affected the drug has not had the
proper effect. A gradual effect may be attained by repeated small doses ; but
when the calming effect is desired a large dose should be given at once ; and
when repeated small doses have not the desired effect, a larger dose should be
given at one time. This procedure is perfectly compatible with a continued
treatment of three or four weeks. This prolonged administration is necessary in
chronic cases with accesses of violent agitation. In some cases collapse may
occur, but is not dangerous to life, and is easily avoided by regarding the thirst,
buccal dryness, heaviness of the head, faintness, diplopia, and, in some cases,
increased agitation, showing individual idiosyncrasy. Morphia is an excellent
antidote. The best preparations of it are Merck's alkaloids. — Archives de Neu-
rologic, July, 1883.

Acetal and Paraldehyde ; their Hypnotic and Analgesic Properties.
Diethylacetal, belonging to the acetal family, and commonly culled by that
name, has been recently recommended by vox Mering as an excellent substi-
tute for chloral. It has a bitter taste, slightly burning, soluble in eighteen times
its volume of water, and soluble in alcohol in all proportions. The experiments
of von Mering made on frogs and mammifers have led him to conclude that
acetal and diethylacetal particularly act on the nerve centres by suspending their
functions, commencing in the cerebrum and extending to the cerebellum and
cord ; in toxic doses they arrest respiration, and later the heart. Von Mering has
used acetal on eight patients. Six slept during the whole day after taking gijss
-sjiij ; the other two, one of whom had a fracture of both calcanei, the other sub-
ject to ataxic fulgurant pains, after taking acetal felt drowsy, and noticed a
marked diminution of pain. None of the eight patients complained of any disa-
greeable sensations after the hypnotic effect had passed off. As acetal is less

1883.]

Materia Medica and Therapeutics.

557

caustic than chloral, Yon Mering recommends that it be substituted for that
drug in ulcerative affections of the digestive canal. It may be given in the fol-
lowing mixture : diethylacetal, ^iij, suspended in f^ss of gum acacia, and fgvj of
orange flower water.

The observations published by Stoltenhoff agree with the conclusions
drawn by von Mering. Stoltenhoff reports the case of an old woman, demented
for five months, very much agitated and suffering with persistent insomnia; opium
had given no relief. He gave grs. xlv of acetal and she slept a large part of the
night. On the next day was given ; she slept through the whole night and
was calm during the next day. This good effect was maintained up to the time
at which the case was reported, the woman having taken over ^x of acetal. In
two other patients of this class, one affected with general paralysis, a daily dose
of produced a calm condition and sleep. In a case of acute mania, a robust
man, who was incessantly excited, a dose of £j gave a quiet night. The seda-
tive and hypnotic effects were apparent in 5-30 minutes after the drug was ad-
ministered, and lasted from 4-10 hours.

The observations of Bekger, of Breslau, on three insane persons were not so
favourable: gijss of acetal gave one and a half hour's sleep to one patient; in
four other cases the effect lasted 20 or 30 minutes, and in eight others there was
no effect at all. Berger has seen it cause vomiting in one case, redness of the
face in two others ; two complained of a heavy feeling in the head and a kind of
inebriety which lasted for several hours. To one patient he gave £jvss of acetal,
and he slept an hour and a half. Leydcn, of Berlin, had still less satisfactory
results with acetal.

Paraldehyde seems to be a much more satisfactory drug. It is isomeric with
aldehyde, and though its hypnotic properties are less energetic than those of chlo-
ral, it may be given in larger doses and with no influence on the heart or intra-
vascular pressure. Of this fact Cervello has been convinced by his experiments
on dogs and rabbits. A man suffering with sciatica took, in three doses, ^ij of
paraldehyde, in aqueous solution, in one hour and a half. Two hours after the
last dose, the patient was sleeping calmly, and continued to sleep for more than
ten hours. Cervello thinks that paraldehyde acts much more promptly on
females, and that, generally speaking, the dose must be three times as great as
that of chloral.

Berger has made eighty clinical experiments with paraldehyde in his hospital
service, and twenty others among his clientele. In twenty cases the drug was given
in the evening, and during the day in sixty cases. The doses varied from grs.
xv to gijss. It was given suspended in sweetened mucilage of acacia with syrup
of bitter orange-peel. Among the eighty experiments made in the hospital,
sound sleep, of several hours' duration, was produced in nineteen cases : in forty-
two, the sleep was not so long (one hour, one and a half hour, and three hours) ;
in nineteen cases there was no soporific effect. The dose, in the favourable cases,
varied from grs. xxx-gj ; sleep came on in ten to twenty minutes after the medi-
cine was taken. When the desired effect was not produced by 5j, an increase to
giss, or even ^ijss, rarely gave a better result; on the contrary, nausea and vom-
iting would come on, with cephalalgia. There were never any excitant phenom-
ena. In his private practice doses of grs. xxx-gj gave the desired results in
twelve out of twenty cases. Berger concludes that this drug will be of service
when chloral is insufficient or when there is a cardiac complication. — Gaz. Med.
de Paris, No. 28, 1883.

558

Progress of the Medical Sciences.

[Oct.

Resorcin in Hyperpyrexia, Intermittent Fever, Anthrax, and Erysipelas.

Resorcin, which has been called "poor man's quinine," is attaining a useful
position in therapeutics. In Dr. Braun's clinic {Wien. med. Presse. i. 1883) it
has been used in over 300 cases of child-bed fever, in all cases where the pyrexia
attained a certain grade, and almost invariably it produced a marked reduction
of temperature, generally to the normal, rarely below, which usually was accom-
panied by more or less sweating. In some cases this was profuse. The tem-
perature after its reduction seldom remained low longer than a few hours, so that
the dose had to be repeated in the evening when a high morning temperature had
required its use earlier. The usual dose was grs. xlv., which sometimes had to
be repeated. In cases where such large doses cause nervous symptoms, smaller
ones are advised to be given and frequently repeated.

In intermittent fever resorcin has a position not far below quinine, although
the dose is larger. Ugo Bassi (Gaz. Med. Ital. Prov. Venet. 1883) reports its
use in twenty cases, which were all cured except three. In one case the attacks
were relieved by the remedy, but it did not prevent recurrences ; this happens also
with quinine. In all the remaining cases the cure was permanent, the patients
being instructed to avoid fresh malarial poisoning. It required only two or three
doses (grs. xxx-xlv.) simply dissolved in water to effect the cure. Larger doses
are not necessary. The great advantage of resorcin over quinine is its cheapness.

Dr. Skibnevsky (Medizinskoje Obosrenije, December, 1882) reports two
cases of erysipelas in which subcutaneous injections of a five-per-cent. solution
caused a rapid disappearance of the symptoms. From ten to twenty injections
were made at one time into the affected area, and in each case they had to be
repeated only once. It is worthy of notice that, in both cases, within about two
hours after the injection not only did the fever disappear, but the temperature
fell even below the normal.

Although resorcin in any form is not absorbed by the healthy unbroken skin,
the contrary is the case when there is any morbid action on the skin, as in lepra,
rupia, variola, scarlatina, or erysipelas, in which it both stains the skin and dis-
colours the urine. In cases of parasitic disease of the skin its use has been
attended by remarkable success. Dr. Justus Andeer has reported a case {Aerzt-
lich. med. Blatt, 1883) of carbuncle in which bacilli were detected, and a guinea-
pig being inoculated with the pus died of septicaemia. Other remedies had been
used locally without much result, when a fifty-per-cent. resorcin-vaseline salve
was applied rather freely upon the pustular erysipelatous surface of the forearm,
covered by a gauze bandage. A good diet was given. After this the pain and
tension diminished, the surface rapidly assumed a more healthy appearance, and
the eruption soon healed. The reporter declares that resorcin, whether in strong
or weak solution, is entirely free from irritation, and never produces any erup-
tion, and is, therefore, to be preferred to all aromatic disinfectants. It is best
used in the form of salve. It is completely innocuous to the skin, and causes
neither hemoglobinuria like naphthol, nor toxic symptoms similar to those caused
by carbolic acid, pyrogallic acid, etc. He does not approve of subcutaneous in-
jections of the remedy. — Practitioner, July, 1883.

1883.]

Medicine.

559

MEDICINE.

Hcemo globincemia.

Prof. Ponfick has recently published an article in the Berliner Klinische
Wochenschrift, No. 26, on haemoglobinaemia and its consequences. It is known
that many agencies have the property of displacing the haemoglobin from the red
blood-disks, so that the colouring matter is discharged into the blood-plasma.
The transfusion of foreign blood, i. e., blood from a donor of different species to
the receiver, burns of the surface of the body, and many chemical substances
(pyrogallic acid, arseniuretted hydrogen, potassic chloride, etc.), possess this
property. Peculiar as is the bond of connection between the stroma of the red
blood-disk and its haemoglobin, yet the union is v^ery easily dissolved. In fact, to
prepare haemoglobin from the dog's blood, it is sufficient to add ether, and keep
in a cool place, then filter the red mass of crystals thus formed, redissolve in
water, and recrystallize. From what has been said, there will be no difficulty in
comprehending the full meaning of the term haemoglobinaemia. The notions
which Ponfick has on the subject may be enumerated in the following fashion.
There are different degrees of haemoglobinaemia. When this state exists the
altered products (of the blood) are disposed of in three directions. The spleen
is enlarged with the fragments resulting from the destruction of the blood — that^
is one direction. The liver secretes an excessive quantity of bile (hypercholia) ;
and lastly, the dibris of the decomposition of the blood (implied in the setting
free into the blood-plasma of the haemoglobin) is excreted by the kidneys. With
limited haemoglobinaemia there is neither haemoglobinuria nor icterus. When the
haemoglobinaemia is greater in degree, some of the colouring matter of the blood
appears in the urine, and there are signs of slight and transient jaundice. Pro-
found destruction of the red blood-elements is followed almost instantaneously by
intense and prolonged haemoglobinuria (associated with exudative nephritis) as
well as marked and severe icterus.

Much food for reflection is offered in these scientific speculations by Ponfick.
The views promulgated may help to throw light on many morbid phenomena.
Good grounds certainly exist for the opinion that the spleen and possibly other
organs are concerned in the destruction of the red blood-disk. A further con-
sideration is the fact that the blood is constantly being destroyed and renewed.
Now, if there be constantly going on a dissolution of the red blood-elements, it
follows that at least a local haemoglobinaemia always exists ; unless, indeed, we
regard the dissolution as always occurring in the solid elements of the tissues con-
cerned. Some physiologists teach that the haemoglobin thus set free is converted,
probably by the hepatic tissue, into bilirubin, the principal colour-constituent of
the bile. There is much plausibility in such a view. Indeed, it is very prob-
able that haemoglobin is the source of all the pigments of the body. Granting
these considerations, we may conceive how, step by step, an increase in the degree
of haemoglobinaemia may entail all the consequences which Ponfick has claimed
for this excessive destruction of the red blood-disks in the blood circulation. The
importance of these plausible conjectures in connection with the explanation of
the occurrence of haematinuria and jaundice, which have been so often observed
in malignant and septic fevers, is obvious. Again, haematinuria has been met
with in purpura and scurvy, also after poisoning by arseniuretted hydrogen or
carbonic anhydride, and as a distinct affection, named paroxysmal or intermittent
haematinuria. The relations which have been observed to subsist between ague,
oxaluria, rheumatism, and this intermittent haematinuria are well worth remem-
bering at this time. If the enlargement of the spleen in ague coincide with the

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excessive production of heemoglobingemia we might expect some corresponding
evidence of the excessive production of blood-pigment. It would perhaps require
no great ingenuity of argument to harmonize these considerations with the facts
observed in acute and chronic malarial poisoning. Hasmoglobimemia may be
looked upon also as the precursor of icterus in the form which has been known
as " hamiatogenous" jaundice. The actual coexistence of hemoglobinuria and
icterus is spoken of by Ponfick, and he believes that the haemoglobin passes over
unchanged in the urine when the liver is incapable of converting it into bilirubin,
the power which the liver has in this direction being limited. — Med. limes and
Gazette, August 18, 1883.

Renal Form of Typhoid Fever.

Dr. Didion, who chose this subject for an inaugural dissertation, comes to the
following conclusions. Typhoid fever produces a renal congestion, which plays
an important part in the course of the disease. Albuminuria is almost constant,
but generally slight and temporary ; Avhen abundant, it is a sign of true nephritis.
The renal inflammation is both parenchymatous and interstitial, and produces cer-
tain characteristic symptoms, such as asthenia, stupor, dryness of tongue, oedema
of the face and legs, lumbar pains, cutaneous eruptions (pemphigus, ecthyma,
boils), and an alteration in the urine, which has a l-eddish colour and the odour
of boiled bread; in the deposit, red and white blood-corpuscles are found, as well
as casts ; the urine contains a large quantity of albumen. The diagnosis can
easily be arrived at by the above-mentioned symptoms. The termination is
often fatal, either from asthenia or uraemia.

As to the treatment, Bouchard recommends carbolic acid and the salicylates,
Polli the sulphites, Klebs the benzoate of potash. Leeches, mustard poultices,
and cupping in the lumbar region, are useful ; but blisters, even with the addition
of camphor, must be avoided. In certain cases, the disappearance of the symp-
toms is accompanied by abundant diuresis, which ought, therefore, to be favoured
if possible ; but all diuretics are not equally good, those which possess irritating
properties must be avoided. The best in these cases is milk, pure or mixed with
water. Whatever may be the way in which it acts on the kidneys, it is always
well borne, and its action is double ; it increases the secretion of urine, and
hastens the elimination of toxic principles, without producing any irritation, even
in the most acutely inflamed kidney. Subcutaneous injection of pilocarpine
might perhaps be useful ; in one case, when the skin was dry and burning hot,
Dr. Didion injected twice daily one-sixth of a grain of pilocarpine, and under its
influence the skin became moist and abundant sweat was produced ; the tongue
also was less dry than before ; the temperature fell in two days from 105.8° to
98.6° F. ; but three days later the patient died, after the temperature had once
again reached 104° F. New investigations are necessary before we can arrive
at definite conclusions. As for the cold baths, Gubler thinks that they are con-
traindicated in case of nephritis, but Libermann considers their use as surely
beneficial in spite of it. Several patients who had been subjected to that treat-
ment did not complain of any inconvenience, and cold lotions rapidly applied to
the trunk and limbs with a sponge seem to relieve the patient, lower the tempe-
rature, and re-establish the functions of the skin. All these advantages must be
weighed against the danger of a renal congestion ; but further experience alone
can show which treatment is most advantageous. — British Med. Journ., July 7,
1883.

1883.]

Medicine.

561

Treatment of Cholera.

Dr. B. Ward Richardson concludes a series of papers on the Treatment of
Cholera during the First Stage and during the Fever of Reaction, as follows: —

In cases where it is clearly shown that the symptoms have followed indulgence
in any kind of food or fruit that has created stomachic or intestinal derangement,
1 have found it good practice always to administer a dose of castor oil, and, if
necessary, to repeat the dose. After Dr. George Johnson's essay on administra-
tion of castor oil I was bolder than before as to this plan, and, I think, with
favourable results. So soon as the oil has acted by the bowels — for, singularly
enough, it rarely excites vomiting — I have given in every case a mixture contain-
ing creasote, opium, and camphor. The following is a good form : Pure crea-
sote, Tftxij ; compound tincture of camphor, ^ss; pure glycerine, ^ss; dis-
tilled water, ^ss — to make a mixture of twelve doses, of which one fluidrachm
in a wineglassful of water may be taken every hour until the vomitings and the
discharges from the bowels are relieved.

Creasote in small repeated doses, in combination with opium and camphor, as
formulated above, checks the choleraic discharge, relieves the spasm, and is the
most demonstrably curative of any remedy I have known.

Treatment in the Stage of Reaction. — I doubt if there be any stage of cholera
in which more careful treatment is demanded than the stage of reaction. One is
very apt to be deceived by the transition from the cold stage, of collapse to the
stage of fever. At first all seems well. The cold extremities become warm ;
the cold breath, so characteristic of cholera that it would yield a diagnosis almost of
itself to those who have seen cholera, is again natural ; the cramps have ceased ;
the mind of the patient is easy ; the anxious, shrunken expression has departed ;
the voice has lost its bleating sadness ; everything bids fair for recovery. An
hour or two passes, and all is changed ; there is intense fever, dry skin, parched
tongue, nausea, often deliriums and too often a second collapse, assuming what
was once commonly called the typhoid type.

The reaction is as close as it can be to that which succeeds exposure to extreme
cold or starvation, and the treatment required to meet it is practically the same.

When the stage of collapse has decidedly passed away, the safest practice is to
prevent every artificial means of stimulation. Hot drinks, rich foods, alcoholic
stimulants, over-clothing, over-heating of the air of the room, are all to be speci-
ally avoided. The patient may continue to drink cool watery fluids, he may be
allowed watery fruits like melon, but he must not be rapidly fed. He may be
relieved of medicine. He must be allowed to rest and sleep.

If, in spite of all precautions, the febrile state does occur, and if the pyrexia
runs high, the plan is to combine the application of the cold band to the cervical
region and to the head, with administration of cool drinks in abundance, and con-
tinued absolute rest.

Medicinally, ammonia, largely diluted with water and milk, is the agent most
likely to retain the fluidity of the blood and prevent septic change. Or ammonia
might be exhibited by inhalation in the form of ammoniated chloroform, after the
manner I have recently suggested for the reduction of zymotic pyrexia. — Med.
Times and Gaz., Aug. 25, 1883.

Diabetes in Children.

Senator, in speaking of the pathological appearances of diabetes occurring in
children, remarks that the opportunities for observing them are few in number
not only because the disease rarely causes death, but also because the patients, on
No. CLXXII Oct. 1883. 36

562

Progress of the Medical Sciences.

[Oct.

account of the long course of the disease, seldom remain in the hospital. The most
frequent changes are found in the brain; inflammatory and degenerative conditions
of the fourth ventricle often occur, also tumours in that situation or in the cere-
bellum ; these tumours are tubercular or gliosarcomata ; there are also in some cases
syphilitic exostoses of the skull, together with gummata of the liver. Prof. E.
Hagenbach reports the following case : A girl four and a third years old, and
previously healthy, began in the winter of 1879 and 1880 to be very fretful, to
drink a great deal of water, and to lose her appetite ; soon after she would not
take anything but milk and water, and cried out for it in her sleep at night. The
renal secretion was very large in amount, and there was decided emaciation.
There was no history of injury ; the parents were living and healthy, and there
were three other healthy children. Hagenbach first saw the child December 23,
1880, after she had been in this condition for a year ; she was pale and feverish,
very restless and irritable. Nothing abnormal was discovered on examination of
the chest. She drank a great deal of water. The specific gravity of the urine
was 1004 ; no albumen ; no sugar. December 24th she vomited. December
25th she complained of headache. December 27th there was sudden loss of
consciousness, with stiffening of the limbs and a quick pulse. On the following
day there was converging strabismus, twitching of the right arm and leg, and the
right side of the face, and great somnolence. January 2d the pupils were dilated
and not reacting, the right pupil being narrower than the left. January Gth death
took place without convulsions. The patient passed immense quantities of urine,
which it was impossible to measure accurately, during the latter part of her life ;
the specific gravity varied between 1000 and 1004, and there was no sugar found
at any time, although repeated examinations were made. The post-mortem
showed the principal changes to be cheesy tubercle of the infundibulum ;
meningeal tubercle and distension of the fourth ventricle and the lateral ventricles ;
tubercular peribronchitis at both apices, with a few fresh miliary tubercles of the
left lung; follicular ulceration of the large intestine: interstitial hepatitis;
hemorrhages in the kidney, and hemorrhagic erosions in the stomach and
duodenum. — Boston Med. and Surg. Jouru., July 26, 1883.

Meliluria after Scarlatina.
Dr. Zinx, of Bamberg, reports the following case: January 27th a boy, four
years of age, previously strong and healthy, and of healthy parentage, was seized
with scarlet fever and diphtheria. The eruption faded on the seventh day, and
the diphtheria gradually subsided. On the thirteenth day an otitis externa
appeared, and stormy vomiting with rapid development of oedema and ascites,
the urine now for the first time showing evidence of nephritis, being lessened in
quantity, and showing a large amount of albumen and numerous casts and blood
corpuscles. In a few days the more dangerous symptoms passed off. the patient
being treated with hot baths and injections of pilocarpine, and a diffuse diuresis
having set in the oedema and ascites quickly disappeared. Although the appetite
improved considerably the little patient's strength did not return, so that he
remained in bed during the whole month of March. Early in April, on attempt-
ing to walk, he was found to have paralysis of the right leg. which, however,
soon passed off under the administration of iron without electricity. At this time
also a slight amount of albumen appeared in the urine. The next symptom which
presented itself was increased action of the heart, even noticed by the child
himself. On the 10th of April the urine had a specific gravity of 1030, and a
considerable amount of sugar. The amount of urine passed in twenty-four hours
decreased to between 750 and 1000 cubic centimetres. The appetite was good,

1883.]

Medicine.

563

but not excessive ; the thirst was not noticeably increased, and nothing else
abnormal was discovered. The child was placed on an exclusively meat diet,
with milk, eggs, and red wine, and by the end of April there was only one per
cent, of sugar in the urine, and by the middle of May one-fourth per cent.
From this time the child improved in strength, and was allowed to have a mixed
diet, and by the middle of June the urine was free from both sugar and albumen,
and the patient soon became as strong and well as ever.

This case is of unusual interest, both from the rarity of its occurrence as a
sequela of scarlet fever and from its unusually favourable result. Ktilz, in his
article on diabetes mellitus in Gerhardt's Handbuch der Kinderkrankheiten,
states that out of 111 cases of this disease only seven recovered. The same
author mentions that the cause in two cases appeared to be measles, but no case
is attributed to scarlet fever. Redon, in his collection of cases of diabetes,1
gives, among other causes, weakness from previous diseases, such as measles,
scarlet fever, typhoid, etc. Yet on looking over the original articles from which
he gathers his cases scarlet fever in no instance is found to be a cause. Thomas,
in Ziemssen's Handbuch der Allgemeinen Pathologie, Band i., s. 290, speaks of
the appearance of sugar in the urine with cerebral symptoms occurring during
the stage of fever in scarlet fever, but not as a sequela of that disease. In view
of this case of Zinn's it would be well during a convalescence from scarlet fever
to examine the urine carefully for sugar as well as albumen where the patient
does not gain in general strength as fast as he ought to. — Boston Med. and Surg.
Journ., July 26, 1883.

Acetonuria and Diabetic Coma.

The termination of diabetes by acetonuria or acetone intoxication, if one may
judge by recent statistics, seems to be much more frequent than is generally
supposed. S. Mackenzie has noted it 19 times in 37 cases of diabetes, and 26
times in 43 other cases observed in Guy's Hospital. From these facts he
believes that he is justified in concluding that young diabetics frequently die in
coma, the disease developing in these with a certain acuity, and the lungs being
sound or invaded only by the lesions of commencing phthisis.

In a work on diabetic coma Frerichs reports no less than 25 cases coming
under his own observation, of which he made detailed observations. He divided
these into three groups : the first comprehending cases of diabetes with rapid
death, the patients having died in a comatose state in a few hours after being
seized, without prodromal symptoms, with general feebleness, failing pulse, and
cold extremities. Some of the patients in this first group already had marasmus.
In the second group the comatose state was preceded by prodromal symptoms,
general feebleness, gastric symptoms, nausea, vomiting, and obstinate constipation,
or by some local affection such as dental abscess, pharyngitis, phlegmon with
tendency to gangrene, bronchitis, or broncho-pneumonia. Before falling into the
somnolent and comatose state the patients have headache, agitation with delirium,
great pain, sometimes true accessions of mania, and dyspnoea ; at times they make
deep inspirations and expirations ; the pulse becomes rapid and feeble ; the
temperature descends below the physiological level. This state lasts from three
to five days. In the third group Frerichs places the diabetic patients who, with-
out the least dyspnoea or pain, with firm pulse and well preserved vital forces,
are suddenly taken with headache, a kind of intoxication, and finally somnolence,
coma, and death.

The numerous remedies which have been proposed against these accidents

1 Virchow und Hirsch, Jahrb., 1877, Band ii.

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Progress of the Medical Sciences.

[Oct.

seem to be equally inefficacious. Frerichs cites, among others, transfusion, the
administration of oxygenated water, stimulants, weak solutions of phosphate and
chloride of sodium, subcutaneous injections of ether, camphorated oil, antizy-
motics, carbolic acid, salicylic acid, etc. Of the causes of diabetic coma we are
still ignorant ; the alterations of the nerve centres, as offered in explanation by
some, are not constant ; others speak of thickening of the blood by an accumu-
lation of sugar in it, a morphological and functional alteration of the red
globules. This gratuitous hypothesis has led to dangerous therapeutic measures ;
others have attempted to unite diabetic coma and uraemia by ascribing the former
to insufficient excretion of urine. Frerichs relates a case of uraemia in a diabetic
which conclusively proves that there can be no possible assimilation between the
intoxication of Bright's disease and that of diabetes which produces fatal coma.
Ebstein has attributed diabetic coma to a retention of the excrementitious products
of the blood, occasioned by a necrosis of the renal epithelium at the level of
Henle's tubes. This lesion is too inconstant to explain the result. Frerichs has
observed that in diabetics the epithelial cells of the tubules were constantly the
seat of a hyaline degeneration, due to an accumulation of glycogen in the cells.
The sole fact of its constancy in diabetics, who have succumbed to it matters not
what complication of this degeneration, cannot be held to be the cause of the
comatose condition.

Frerichs has never been able to discover traces of fat emboli in the pulmonary
vessels of the glomeruli of the kidney, of the liver or brain, as has been suggested
as a possible fact in the pathogenesis of diabetic coma. In fine, says Ricklin,
it is commonly admitted to-day that acetone and diacetic ether, which for a long
time have been considered as causes of diabetic intoxication and coma, have no
part in its development ; diacetic ether pre-exists neither in the urine nor in the
blood, and both acetone and diacetic ether are frequently injected into the veins
of animals in laboratories.

Jaksch has shown (Zeitschr. f. Physiol. Chem., t. vi. 541, 1882) that acetone is
a product of malassimilation which is found in the blood and urine in the normal
state, and that it is increased in certain pathological sates ; he says that every
febrile affection, from whatsoever cause, is accompanied by acetonuria ; and that
the quantity of acetone eliminated by the urine, which may reach five centigrams
in twenty-four hours, is in direct proportion to the intensity of the fever. Jaksch
has seen cases of diabetes in which only normal quantities of acetone were
eliminated by the urine ; other cases present a true acetonuria, the urine turning
red when heated with perchloride of iron. In still others, advanced diabetics,
this reaction coincided with the presence of a considerable quantity of acetone in
the urine. Of this third class many patients succumb to diabetic coma. Jaksch
has twice found pronounced acetonuria in young men suffering with gastric trou-
bles, saburral tongue, anorexia, constipation alternating with diarrhoea, cephal-
algia, slight tumefaction of the spleen without fever. In these cases the urine
heated with perchloride of iron gave the red color. He has also found a large
quantity of acetone in the urine of persons with hydrophobia, as well as in cases of
cancer of the stomach, in a case of cancer of the oesophagus, and in one of cancer
of the stomach and pancreas. In another case dying in a state precisely similar to
diabetic coma, the autopsy showed cancer of the pylorus, with metastatic foci in
a large number of organs. (Ueber Pathol. Acetonuria, Zeits. fur Klin. Med.,
t. v. fasc. iii. p. 346.)— Gas. Med. de Paris, July 7, 1883.

Resorcin in Whooping Cough.
In an interesting article, recently published, Dr. Moncoryo, Professor of
Diseases of Children in the Polyclinic of Rio de Janiero, strongly advocates the
employment of resorcin in pertussis.

1883.]

Medicine.

565

He considers the parasitic origin of pertussis as established, .and believes that
resorcin is the proper germicide. Indeed, its parasitic origin now scarcely
admits of a doubt since Burger, of Bonn, published his conclusions, which were
that: 1. The bacilli were only encountered in the sputum of patients affected
with whooping-cough. 2. They appeared in such quantities in the sputum of these
patients that their influence could not be doubted ; and, 3. The intensity of the
case was in direct proportion to the abundance of the leptothrix buccalis. The
experiments and examinations of Dr. Moncorvo and Prof. Silva Araujo fully
confirmed Burger's conclusions.

Having satisfied himself as to the origin of whooping-cough, Prof. Moncorvo
concluded that the most effectual theurapeusis was a local application to the laryn-
geal mucous membrane, and in view of its non-irritating qualities, resorcin
seemed to be peculiarly adapted in these cases. It should be used in an aqueous
solution of one per cent, and applied to the epiglottis and larynx by means of a
camel' s-hair pencil well curved and suitable for introduction into the larynx.
Contrary to what would be expected, the application is not irritating to the
larynx, nor does it bring on a paroxysm of cough, except at the first one or two
applications. The taste and odour, not being disagreeable, increase its value for
this purpose. It is, as we know, harmless when given internally to very young
children even in large doses. It is important that a pure article be used ; pure
resorcin is very white, and occurs in the form of crystalline needles of silvery
brightness. Besides the fourteen cases reported in detail, he has successfully
treated twenty other cases with it, some very obstinate and complicated by
hereditary syphilis, intermittent fever, threatened hydrocephalus, etc. Of the
fourteen cases of which detailed reports are given, many are interesting on
account of the rapidity with which the application caused the disease to disap-
pear ; in eight cases, variously complicated by hereditary syphilis, intermittent
fever, marasmus, diarrhoea, and pulmonary tuberculosis, the disease had entirely
disappeared in six weeks. In fact, of these cases, only two remained uncured
at the end of four weeks, some being completely cured in one and two weeks.

From these facts he feels justified in concluding : —

1. That whooping-cough, whose nature and genesis, up to a very recent period,
have been variously interpreted, may now, on account of recent microscopical
observations, be classed among the parasitic diseases.

2. That the disease appears to be due to the presence of micrococci, which
multiply with great rapidity in the hyperglottic region of the larynx, infiltrating
the epithelial cells, which cells appear to be the elective seat of their develop-
ment.

8. That resorcine, applied directly to the laryngeal mucous membrane, caused,
in every case in which it was employed, rapid decrease in the number of the
paroxysms, marked decrease of their intensity, and recovery in a short time
without the aid of other medication. — Uniao Medica, March, April, and May,
1883.

Pathology of Bronchial Asthma.
Prof. Bjegel, of Giessen, in approaching the consideration of the pathology of
asthma, remarks that there are several distinct questions involved, which are still
more or less imperfectly settled. The first of these questions manifestly is : Is
there really such a function in the bronchial muscles as active contraction, suffi-
cient to affect the calibre of the tubes and to modify the pressure of the air within
the lungs ? Very different have been the answers given to this question by dif-
ferent physiologists — for we must be careful to notice that this is but a matter of
physiology, and not of clinical medicine. Prof. Riegel's results are entirely in

566

Progress of the Medical Sciences.

[Oct.

accordance with the accumulating evidence of the work of recent, as well as of
some of the older and most distinguished, observers ; namely, that irritation of
the bronchial muscles does raise the pressure within the lungs, and that this irrita-
tion may be induced through the medium of the vagus. This point having been
settled, the next question was whether stimulation of the vagus caused acute dila-
tation of the lungs, such as is seen in asthmatical seizures? And this question,
also, Prof. Piegel was able to settle in the affirmative, the pulmonary area
enlarging rapidly when the vagus was galvanized in the neck (in dogs), remain-
ing large during the continuance of the stimulus, and slowly returning to its
normal dimensions when the irritation was removed. Nothing could have been
more easy, or, indeed, more natural, than to conclude after these two series of
experiments that the pathology of bronchial asthma was practically settled ; that
this disorder is essentially a neurosis of the vagus, the dyspnoea due to bronchial
spasm and the pulmonary dilatation being the direct results of irritation of the
great nerve of respiration. Prof. Riegel was too cautious, however, to rush to
this conclusion, and his next set of observations showed the wisdom of his hesita-
tion ; for they distinctly proved that whilst irritation of the vagus unquestionably
produces the phenomena of asthma, it does not do so by causing spasm of the
bronchi. ~No doubt, as has just been shown, spasm of the bronchi is a result of
irritation of the vagus ; but there is a much more important, because much greater
or more extensive, cause at work than this.

The turning-point in the investigation was the discovery that irritation of the
vagus causes the phenomena of asthma, not by acting peripherally — that is,
through the branches to the bronchi — but by influencing the central extremity of
the nerve, that is, the medulla, and so (re(lexly) the muscles of respiration.
When the central end of the divided vagus of the left side was faradized, and
the other vagus cut, the same asthmatic phenomena were produced ; the reflex,
therefore, did not occur through the bronchial nerves, but the respiratory nerves to
the diaphragm and intercostals. That this was the case was completely proved by
section of the phrenics before irritation of the vagus, for the phenomena of asthma
then were entirely absent. An altogether unexpected result was thus reached,
namely, that asthmatical phenomena may be produced rejlexhj through the vagus,
and that the principal portion of the eflfeet is a sudden inspiratory depression of
the diaphragm, followed by its continued tonic contraction. It would thus ap-
pear that the theory of asthma, which represents the disorder as essentially one
of bronchial spasm, must be given up. There can be no doubt that irritation of
the vagus does cause bronchial spasm and moderate dilatation of the lungs, but
this effect has always been regarded as much too insignificant to account for the
symptoms of the disorder as clinically observed ; and now that it appears to have
been satisfactorily proved that besides this peripheral effect there is a reflex effect
of incomparably greater importance, there is no reason why the theory of bron-
chial spasm should be any longer maintained.

Two very obvious objections to the view first stated are anticipated by Prof.
Biegel. Can it be possible, in the first place, that the diaphragm may remain so
long in a state of contraction as to cause the protracted dyspnoea familiar in many
cases of asthma ? There is no evidence to the contrary ; and in the course of
these experiments on dogs the diaphragm was actually seen to remain in a con-
dition of contraction for ten minutes without producing asphyxia. Besides, the
same objection might apply to the muscles of the bronchi, Again, it is a clinical
fact that whilst the inferior lung-border is low in an attack of asthma, it moves in
respiration. Is this fact compatible with spasm of the diaphragm ? As a matter
of fact it is ; whether the phrenic be directly or indirectly stimulated, and the
diaphragm thrown into inspiratory spasm, the lung-border moves slightly in
respiration.

1883.]

Medicine.

567

Lastly, Prof. Riegel cautions us against coming to the hasty conclusion that we
have now settled the pathology of bronchial asthma. Spasm of the diaphragm
may explain some of the phenomena of the seizure, but it certainly will not
explain all. For himself, he still holds that there may be vaso-motor disturbance
and hvperaemia of the bronchi, along with spasm. Still, spasm there is, and the
present investigation shows that it is chiefly a spasm of the diaphragm. — Practi-
tioner, July, 1883.

Fatty Transformation of the Kidney.

Mr. Edwin Rickards, in an interesting paper in the British Med. Journ.,
July 7, 1883, on this subject, says that in fatty transformation of the kidney,
there is a replacement of renal tissue by true adipose tissue, the contour of the
organ being, to a varying extent, preserved. The condition is a rare one, and
the cases on record are few. It has not, as far as I am aware, been before por-
trayed, numerous and excellent as are the illustrations of the various morbid
changes in the kidney by Bright and others.

Whatever be the source of the fat, there can be no doubt that it is not degene-
rated renal parenchyma, and it is equally certain that the fat does not stamp out
renal tissue. It seems probable that the fat is developed to fill up space created
by the breaking down and discharge of renal substance, and that the process is
one of physiological compensation, an effort of nature to prevent a vacuum. The
origin of the fat may be accounted for in three ways : 1, hypertrophy of the cir-
cumrenal fat, which pushes its way into the interior of the organ at its hilum ;
2, hypertrophy of the fat, which normally is found in small amount in the inte-
rior of the organ between the apices of the pyramids ; 3, absorption of fat by the
cells forming the stroma of the organ.

Statistics go to show that fatty transformation of the kidney is frequently asso-
ciated with renal calculus. Even in Dr. Whipham's case (Pathological Society's
Transactions, vol. xix.), a calculus may have escaped from the kidney, and
found its way out of the body through the wound in the thigh. It is reasonable
to suppose the sequence of events in such cases to be renal calculus, suppuration,
and discharge of renal parenchyma and its substitution by fat.

The condition under consideration, though a rare one, must not be left out of
calculation by the nephrectomist.

Case. — Alfred Rowen, aged 24, was admitted into the Birmingham General
Hospital, February 16, 1883. He was a broad-built, well-nourished man. When
seen at 10 A. M., he had extreme dyspnoea, sitting with his arms leaning on the
arms of the chair. The alas nasi and muscles of extraordinary respiration were
working ; his face was covered with beads of perspiration, and a little dusky.
He was operated on for stone twenty years ago. For many years, he had known
that his kidneys were diseased, because he sometimes passed matter in the urine.
Occasionally he wetted his bed. Three weeks ago, he passed blood in his water,
and vomited blood ; he only vomited on that one occasion ; at that time, he com-
menced making a noise in his throat, especially when asleep at night, and so
%>ud that it kept awake fellow-lodgers, and, in consequence, he had to sleep in a
separate room. During the last fortnight, he had been off work, and a great
deal in the house. He had been very drowsy, sleeping during the day in his
chair for two or three hours at a time. He had frequently played cards ; and,
•on many occasions, he had suddenly jumped up, and said : 11 1 must leave off ; I
have got the cramps in my fingers and legs." The fingers and legs would be
drawn during these cramps, which lasted about ten minutes at a time.

When examined in the ward, his breathing was very laboured. The dyspnoea
was essentially inspiratory. The suprasternal notch, the lower intercostal spaces,

568

Progress of the Medical Sciences.

[Oct.

and epigastrium sank in during inspiration. Laryngeal stridor could be heard
at the other end of the ward. He was unable to speak, but protruded his tongue
when asked to do so. His pulse was 1 20 ; temperature 100° ; respiration 40.
Nothing abnormal could be heard in connection with the heart. On rapidly
examining the lungs, mucous crepitant rales were heard over both bases behind.
Examination of the fauces showed nothing. His legs and feet were not cede-
matous. Two ounces of urine were obtained, which was found to be alkaline,
and to contain albumen and a large amount of pus. He became more comatose,
the dyspnoea greater, and the breathing more stridulous. At 1 P. M., tracheo-
tomy was performed, apparently without pain, but without manifest relief. He
died at 4 P. M. on the day of admission.

Post-mortem Examination. — The body was well-nourished. The larynx was
purple and (Edematous. The lungs were (edematous. The heart was normal.
The brain was not examined. The other viscera, except the kidneys, were free
from morbid change. Both kidneys were imbedded in fat. The left kidney,
which was half as large again as normally, on section was found to be trans-
formed into true adipose tissue. Its capsule was thin. At its hilum, there
was a mass of tough, dense tissue, like cicatricial tissue, which extended to the
centre of the organ, and in it was impacted a triangular calculus, the size of a
tamarind stone ; this mass was found to be composed of the obliterated pelvis
and ureter, with bloodvessels mostly collapsed, and connective tissue. The adi-
pose tissue was divided for the most part into pyramidal masses by paths of
connective tissue, which radiated from the calculus. In this connective tissue
ran large bloodvessels. The corpuscles of this tissue were proliferating, and
absorbing fat. In two or three spots, near the periphery of the fatty mass, there
were small patches of condensed tissue, which the microscope showed to be the
remnants of atrophied renal tissue. The ureter remained as an impervious cord.
In the right kidney, there were areas in various stages of degeneration ; the
secreting tissue was reduced to about one-third its normal amount, and this was
intensely inflamed. There were circumscribed masses of putty-like matter, and
several thick-walled empty sacs ; in one sac was a smooth, round calculus, the
size of a pea. The pelvis, which was thickened and dilated, contained a calculus,
weighing half an ounce.

Adenoma of the Kidney.
According to a recent article by Drs. A. AVeichselbaum and Robert W.
Greenish, adenoma of the kidney has hitherto received but little attention in
works on pathological anatomy ; but this is not due to the fact that it occurs un-
frequently ; on the contrary, although not a very common, it is not an uncommon
affection.

Macroscopical Conditions. — As to its situation, adenoma seems to be equally
often found in either kidney. It seems to occur generally in the neighbourhood
of the upper or lower end, and most frequently in the cortical portion, and rarely
in or near the pelvis of the kidney. Whenever it occurs in close proximity to
the outer surface of the kidney the capsule is involved. As a rule, there is only
one adenoma of a kidney, though two may be present, and cases have been found
in which a number have occurred at the same time. It occurs in both kidneys
at the same time in about 20 per cent, of all cases. The size of the growth may
be as large as a walnut or hazel-nut, seldom so large as an egg, or so small as a
millet-seed. Its consistence is usually the same as that of the normal kidney-
substance, with the exception of those cases in which fibroid or fibrous metamor-
phosis has taken place, or when fatty degeneration occurs.

From an histological standpoint, adenomata of the kidney may be divided into
two principal forms — the papillary, and the alveolar : —

1883.]

Medicine.

569

Papillarij Adenoma. — When papillary adenoma is completely developed, it is
separated from its surroundings by a capsule more or less thick, and lying either in a
single or several small cavities, the spaces being completely or partially separated
from one another, and are filled with papillary growths. These grow out from one
or more centres of the cavity wall, with a vascular network, sometimes abundant,
and again deficient in round and spindle cells. When one or several growths are
examined they somewhat resemble a tree. The walls of the cavity are lined with
a layer of epithelium, the cells of which have various forms and sizes, though the
cylindrical epithelium is the type most usually found. Not infrequently the epi-
thelial cells have undergone a fatty degeneration, and in some cases pigment
granules are also found. In every case in which the tumour has several cavities,
there is found between them a fibrous web, or kidney substance. In the latter
case the uriniferous tubules are easily seen variously compressed, or distended
with colloid matter, whilst Malpighian capsules have undergone fibrous degene-
ration, or are transformed into colloid cysts. When more recent stages of papil-
lary adenoma are observed, however, it is seen that it is not limited by the sur-
rounding kidney substance. It is made up of numerous cavities containing gland
lobules which increase from the periphery toward the centre ; the cells bearing
a striking resemblance to the epithelium of the collecting tubes of the cortex.
The lobules lie so close together that there is scarcely room between them for a
fine connective tissue stroma, though in some places there is quite a wide separa-
tion.

Alveola?* Adenoma. — This is shown, as its name indicates, by an exquisite
alveolar structure. The alveoli are of various sizes and shapes, the smallest
being less than the cross-section of a convoluted tubule. They are round,
oval, cylindrical or irregular in shape, and contain epithelial-like cells, or there
may be a central fissure or a complete lumen. The cells have a peculiar charac-
ter, being generally large, polyhedral or prismatic, or wedge-shaped, still free
from retrograde metamorphosis, and lie in a homogeneous or granular proto-
plasm. Between the alveoli is a very spare connective tissue stroma, which is
structureless, or contains spindle-shaped cells, and in which the bloodvessels
ramify. When the alveolar adenoma attains a certain size, like the papillary
adenoma, it becomes invested by a capsule. Whilst both the papillary and
alveolar adenomata have clearly defined forms and are easily recognized apart,
during their genesis they so closely resemble each other that they can scarcely be
distinguished.

Few tumours are so certain to undergo a retrograde metamorphosis as adenomata
of the kidney, the metamorphoses taking place in the following order as to fre-
quency : 1, fatty ; 2, fibroid; 3, fibrous ; 4, cavernous and pigment metamorphosis;
5, cystic degeneration ; and 6, colloid degeneration with the formation of concre-
tions in the stroma.

Differential Diagnosis — The diagnosis between adenoma and carcinoma is
most important. Alveolar adenoma may easily be confounded with carcinoma,
as not only the alveolar structure, but the cells resemble those of a carcinomatous
tumour, the adenoma cells being scarcely less polymorphous than cancer cells.
But after an adenomatous tumour has attained a certain size it possesses a cap-
sule, in which respect it differs from carcinoma. A careful microscopic examina-
tion, however, will decide the diagnosis.

From fibro-sarcoma of the kidney adenoma is diagnosed by the fact that fibro-
sarcoma occurs in old age, and only in the medullary substance of the kidney,
and by the well-known microscopic appearances of sarcoma. Adenoma is easily
diagnosticated from hsematangioma cavernosa, and from cystic disease of the
kidney by the macroscopic and microscopic appearances. — Medizin. Jahrbiicher,
1883, Hft. ii.

570

Progress of the Medical Sciences.

[Oct.

The Nature of the Albuminuria of Bright' s Disease.

Semmola, of the University of Naples, has recently communicated the
results of his last researches on this subject to the Academy of Medicine, of
Paris. It is now quite well established that the term "Bright's disease" is
defective, and should only be considered as a general term under which different
lesions of the kidney may be grouped, differing in seat and in the nature of their
processes. Formerly the different lesions observed in the kidney were considered
as the successive phases of the same disease ; at present no one retains this idea.
The name "Bright's disease" should be reserved for permanent, chronic albu-
minuria, for diffuse parenchymatous nephritis. What first produces the passage
of albumen into the urine? Gubler. Jaccoud, and Semmola hold that the origin
of the disease is in an altered state of the Iflood. Under some special influence
the albumen of the blood is altered or increased, and then becomes capable of
passing through the glomeruli. Others, as Dujardin-Beaumetz, hold at the same
time to an alteration of the blood and some lesion of the kidney as the cause.

In his latest researches Semmola has endeavoured to show that the passage of
albumen through the kidney presupposes no real lesion, but that this is a result ;
that the albumen of the various albuminuria? cannot be distinguished chemically,
whilst a high degree of divisibility of albumen always denotes true Bright
symptoms; that the bile of Bright subjects contains albumen; that the saliva
and perspiration also contain it ; and that the primary cause of the affection should
be sought for in some alteration of the nutritive functions of the skin. He thinks
that experimental facts fully justify this theory.

The experimenter has endeavoured to reproduce as nearly as possible the pro-
cesses involved in Bright's disease. With this view he has suddenly introduced
a large quantity of albumen into the blood, and has cautiously injected white of
egg, in small quantities at first, into the subcutaneous tissue of dogs, which were
kept under its influence for more than twenty days. He has kept dogs under its
influence for thirty days, making daily injections of f^ij^s to more than f§ij of
white of egg. After four or five days the kidneys become congested, and if the
quantity injected be large renal hemorrhage occurs. After seven or eight days
leucocytes appear, and fatty degeneration of the epithelium sets in ; and after fifteen
days the kidney commences to get fatty. If the experiment is kept up> toward the
twenty-fourth day the lesions of the kidney are almost identical with those of
interstitial nephritis. The introduction of albumen into the blood causes an
albuminuric dyscrasia, as shown by the fact that the quantity of albumen elimi-
nated is greater than that injected. The bile becomes charged with albumen,
and Semmola thinks that he is authorized in stating that he has realized artifi-
cially the natural morbid process. But the facts here show that the albuminuria
is the primary, and the renal lesion the secondary lesion.

As to the primary cause of albuminuria, Semmola is convinced that it must
be sought in some alteration of the nutritive functions of the skin.

In making the experiments he used different albuminous substances, as serum
of blood, yolk of egg, and milk. With these the effects were different from
those caused by white of egg injections. With blood serum the renal process
was less rapid, and no functional alteration was caused by injections of yolk of
egg and milk. — Revue M6d. Frang. et Etrang.. June 9, 1883.

Semmola has been convinced for three years, after a long experience, of the
many imperfections in the chemical reactions for differentiating the different
kinds of albumen. He has, therefore, turned his attention to the degrees of
diffusibility of the albuminoids of the blood in the different albuminuria?, and
lie is convinced that the great secret to be studied lies in the different gradations

1883.]

Medicine.

571

of the albuminoids b}' reason of their diffusibility, or, in other words, their apti-
tude for performing their functions in the nutritive processes ; and has arrived at
the following conclusions : —

1. The albuminoids of the blood of Bright subjects are much more diffusible
than the albuminoids of the blood in other kinds of albuminuria (mechanical
albuminuria).

2. In Bright subjects of the first stage, and therefore curable, if the blood
serum is examined before and after recovery, it is seen that the diffusibility of
the blood albuminoids augments, diminishes or ceases in perfect relation with the
quantity of albumen eliminated by the urine. Hence it is evident that the degree
of diffusibility of the blood albuminoids constitutes the true point of departure of
the albuminuria of Bright' s disease.

3. This physico-molecular constitution of the blood albuminoids which char-
acterizes their non-assimilability, and which consequently causes their forced
elimination, is caused by a defect, greater or less, of the cutaneous functions. In
support of this view Semmola brings forward a number of laboratory experiments
and clinical observations which clearly prove the relation existing between the
activity of the cutaneous functions and the alteration of the diffusibility of the
blood albuminoids, or their degree of assimilability. He examines, by com-
parison, the degree of diffusibility of the blood albuminoids before and after
varnishing the skin over a more or less extended portion, so that the animal may
live a sufficient time. He has found that, all things being equal, the blood serum
of these animals presents at least one-third of the principal albuminoid principles
which become diffused if the varnishing occupies so much as one-half of the
cutaneous surface. In these cases albuminuria is also seen, and the bile of these
animals contains albumen in the proportion of three to five in one thousand.

As to the clinical observations, he has collected a series of cases of chronic
eczema and psoriasis which alternated in their appearance on the skin with albu-
minuria, and which were finally cured by a long hydrosudopathic treatment. He
relates one case of cutaneous seborrhoea in which the skin perfectly reproduced
the experiment of the varnished dog. Water did not moisten it, and the patient
was always cold ; for a long time he felt the least breath of air, and became pro-
foundly cachectic. He had albuminuria, and it was only after a long course of
hydrosudopathy that he was completely cured ; the albuminuria never reappeared.

Semmola thinks, therefore, that it is incontestable that the first stage of Bright' s
disease is constituted by a profound modification of the albuminoids of the blood
which succeeds in proportion to the progressive enfeeblement of the respiratory
functions of thje skin, under the influence of cold and moisture, which are, in his
opinion, the fundamental causes of true Bright's disease. This action of damp
cold is very slow, and Bright subjects are already victims of the disease before
they are aware of it. At this period there already exist the three characteristic
symptoms of the disease in their order of sequence : 1. Increasing diffusibility of
the principal blood albuminoids, and, consequently, increasing diminution of their
assimilability. This chemical state he calls etlxer albuminuria. 2. Diminution of
the quantity of urea on the one hand, and, on the other, forced elimination of
.the albuminoids, by all the emunctories whose office is organic depuration, pri-
marily the kidneys.

From these facts he was led to analyze the bile of Bright patients after death,
and he found that the distinguishing feature of Bright albuminuria as compared
with other albuminurias is, that on analyzing the bile post-mortem, albumen is
found in the bile in the first case and not in the second. The sweat and saliva,
artificially produced, present the same differences as regards the presence of

572 Progress of the Medical Sciences. ["Oct.

albumen. The final conclusion which he draws is of great interest because it is
grouped with the differences already noted in the different albuminurias. In the
albuminuria of Bright's disease there is a loss of albumen which the organism
produces through its different emunctories in order to rid itself of the albuminoids
which have already become non-assimilable ; and in the other varieties of albu-
minuria (mechanical, nephritic, etc.) elimination of the albumen is due to a
purely local cause which depends either on the degree of pressure of the renal
circulation or upon epithelial alterations.

To demonstrate this theory, built upon laboratory experiments and clinical
observation, one step remained — the experimental demonstration that the non-
assimilable albuminoids (and therefore foreign to the organism) are capable of
producing a renal process analogous to that of Bright nephritis by the fact that
they can pass through the renal filter ; this Semmola has demonstrated by a long
series of delicate and conclusive experiments. He injected albumen into the
areolar tissue, and rejected the common experiment of injecting white of egg
directly into the blood, being convinced that albumen injections into the blood
cause troubles too profound to obtain a complete resemblance to ether albuminuria
or to ether alb urn in o sis caused naturally. He injected variable quantities of white
of egg — from fgv to f^ijss daily — always keeping an accurate record of the
weight of the animal in order to establish a constant relation between it and the
amount of albumen injected. After the second day there gradually came on
hyperaemia, sometimes simple, then accompanied by globular extravasation into
the capsule, and even into the interior of the uriniferous tubules. The capsule
was distended by an amorphous or granular material having the characteristics
of albumen. Later, tumefaction appeared, migration of lymphoid cells, advanced
fatty degeneration, epithelial necrosis, and even proliferation commencing in the
areolar tissue in the animals which had for a long time resisted albuminous injec-
tions. In order to confirm these experiments they were repeated with other
and less heterogeneous substances than white of egg — such as the yolk of egg,
blood-serum, albumino-peptones, and milk.

Prof. Semmola does not think it necessary to give in detail the particulars of
these comparative experiments ; at present it suffices to say that the more the
chemico-molecular constitution of the albumen approaches that of normal blood
albumen, the less injurious will be its passage through the kidneys. Thus, injec-
tion of blood-serum into the subcutaneous areolar tissue is followed by albuminuria,
but, other things being equal, it produces less slowly renal irritation, which is
more feeble and transitory. He has observed, lastly, in dogs an albuminuria
more or less developed in relation to the quantity of albuminoids injected, and
more or less pronounced according to the degree of diffusibility of the albuminoids
of the blood-serum. Anasarca never appears when small quantities are injected,
although a minute quantity of albumen is eliminated by the kidneys. These
facts also confirm, what Semmola has clearly shown, that the chemico-molecular
constitution of the albuminoids of the living organism is of the greatest varia-
bility, and that a mere trifle, the simple passage through a living membrane, is
capable of modifying them, and even rendering them non-assimilable, diffusible, in
other words, and incapable of performing their functions in the work of nutrition.
— Progres l\Ud., June 16, 1883.

Relation between Serum- Albumen and Globulin in Albuminuria.

This subject has been recently thoroughly investigated by Prof. F. A. Hoff-
man. He finds that ascitic fluid contains less albumen than the serum of blood.
This is not extraordinary ; albumen diffuses slowly through animal membranes,

1883.]

Medicine.

573

and when we make experiments on dialysis of albuminous fluids the dialysate
always contains less albumen than the original fluid. But curiously enough the
proportion of globulin and of serum-albumen in the ascitic fluid is tolerably near
that of the blood, whereas in ordinary dialysis globulin passes through more
slowly and in less quantity than albumen. This shows that transudation in living
tissues goes on in a different way from dialysis outside the body. In albuminuria
the relation of globulin to albumen varies much, and varies greatly in the same in-
dividual at different times of the day. Improvement in the condition of the patient
is always marked by a diminution in the proportion of globulin. This is generally
associated, but not always, with a diminution in the total amount of albumen. The
relative proportions of albumen and globulin do not depend upon histological
changes in the kidney. All kinds of proportion may occur in each form of kidney
disease, but the proportion is of great practical value, inasmuch as it depends upon
the intensity of the morbid processes going on in the kidney. In two persons
suffering from the same form of kidney disease, the condition of the one with the
smaller proportion of globulin is better. The proportion of globulin to albumen in
albuminuria is often many times less than in serum. This condition differs greatly
from what occurs in ascitic fluid, and agrees with what occurs in artificial dialysis.
We should expect that this condition would be best observed in cases of slight
lesion of the glomeruli, but on the contrary it is found that in cases of congestion,
where we might be apt to assume that the albumen transudes through the glomeruli,
the relation of albumen to globulin is the same as in ascitic fluid. In acute and
chronic nephritis the rule may be laid down that when the lesions are slight the
relation of globulin to albumen agrees with that of ordinary diffusion through
parchment paper, viz., that the albumen much exceeds the globulin. The
greater the lesion, the more does the proportion resemble that in ascitic fluid,
viz., the more nearly do the quantities of albumen and globulin become equal. —
Practitioner, July, 1883.

H oemato-Chyluria and Chyluria,

Though the hsemato-ehyluria of tropical climates has long been known, it is
only within the past fifteen years that its parasitic origin has been demonstrated.
Wucherer first described the parasite causing hsemato-ehyluria from cases
observed in Brazil in 1859. He found, in the urine of a woman, a microscopic
worm with a very fine, tail-like appendage, a blunt head with a central point,
and a transparent, granular-like body ; its diameter was equal to that of a leuco-
cyte, its length being sixty or seventy times as great. In 1870, Crevaux observed,
at Guadaloupe, a nematode worm 265 mm. long, and .01 mm. wide, having all
the characteristics of Wucherer' s parasite. It was very active, its progress was
rapid, and its contorsions energetic.

Lewis found the embryos of this parasite in the urine of a score of chylurics in
India, and in the blood a filaria to which he gave the name jilaria sanguinis
hominis. It was, then, established that haemato-chymria of tropical countries
coincided with the presence of a particular nematode in the blood. Recent
researches have confirmed this view. Mr. Spencer Cobbold has also found a
parasite in a specimen of blood sent to him from Australia, and proposed to call
it the Jilaria Bancrofti. It is certain, however, that Bancroft's description is
that of a worm as thick as a hair, and three or four inches long ; being altogether
different from the parasite described by Wucherer and Crevaux. The distmna
haematobium of Bilharz and Harley differs also from the filaria which Damaschins
found in a Zanzibar negro. This man had intermittent attacks of milky
urine containing fat in emulsion, fibrine, red and white blood globules. He was

574

Progress of the Medical Sciences.

[Oct.

an hasmato-chyluric. In his urine were found embryos analogous to those con-
tained in the stomach of mosquitoes which had bitten haemato-chylurk patients.
He also discovered in his blood, but only at night, the true filaria of Wucherer
and Crevaux. When the urine ceased to be chylous, the filarial were not found
in the blood.

Dr. Stephen Mackenzie has observed a remarkable case of which he subse-
quently made a post-mortem examination. A soldier, born at Madras, of Euro-
pean parentage, found, after arriving in England, that his urine was more abun-
dant, turbid, slimy, and by degrees quite milky. Later he was seized with vio-
lent pain extending from the left loin to the testicle. The urine averaged 120
ounces per diem, sp. gr. about 1010, reaction neutral or faintly alkaline, no sugar,
a little albumen. Urea G per cent. Ether readily removed the milky colour.
The blood at night contained numerous filariae, the maximum being reached at
midnight. None were found during the day. By inverting the order of his life,
sleeping during the day, and being awake at night, the filarial attained their maxi-
mum at noon. Symptoms of pneumonia developed at the left apex, followed by
abscesses at the root of the neck and left shoulder joint. These were opened ;
from this time the urine ceased to be milky, and the filariae disappeared. The
patient finally died of right empyema. The kidneys were slightly enlarged,
and in the early stage of suppurative nephritis. The mucous membrane of the
bladder was thickened, covered with mucus, and contained extravasations. The
abdominal lymphatics were greatly dilated. The thoracic duct was dilated below
and obliterated above. The lymphatics of the left kidney were dilated and con-
tained calculi. No trace of the parent worm was found; nor any communication
between the dilated lymphatics and the urinary passages. Hamiato-chyluria of
tropical climates is endemic in Brazil, the Bourbon Islands, the Island of Mau-
ritius, in India, Australia, and other places. Its course is more or less irregular,
during which the urine is sometimes sanguinolent, sometimes milky.

Chyluria may last for several years without gravely compromising the health.
Crevaux cured a case by administering copaiba, and Wortabet has cured the he-
maturia, as seen in Egypt, by spirits of turpentine. The balsams seem to be
indicated. Sometimes the disease is cured spontaneously, or under the influence
of an acute intercurrent disease. No reason can be assigned for the fact that the
filarial only appear in the blood during the night.

All cases of chyluria are not parasitic. Gubler has described cases of oily
urine, and Robin thinks that the chyluria of our climate is only an exaggeration
of what Gubler describes. It differs from haemato-chyluria by the absence
of filarial and hematuria. — Progres M&d., July 14, 1883.

Treatment of Leprosy.

The treatment which Surgeon-Major Peters has adopted at the Leper
Asylum at Belgaum, during the last two years, consists, he says, of: 1. Local
applications. — The patient was made to rub carbolic acid and sweet oil (1 in 40),
early in the morning for a couple of hours, all over the body, and then bathe at
about 9 A.M. with soap and warm water; afterwards to rub in an emulsion of
gurjon oil made according to Dr. Dougall's formula (viz., gurjon oil 1 part, lime-
water 3 parts, churned well together so as to form a thin ointment of a creamy
consistence) over the affected parts, and fill in the ulcerations with cotton- wool
smeared with the emulsion.

The ulcers healed rapidly, even such as had remained open for several years,
but the anaesthetic parts and tubercles remained much the same; and except in
one or two instances, where it was alleged by the patients that the tubercles were

1883.J

Medicine.

575

softening, I noticed no change in them. This induced me to try f;he cashew-nut
oil, which has been so successful in the hands of Dr. Beauperthuy. The result
of my trial was so satisfactory, that some of the oldest patients, who had no hope
of being ever relieved in the slightest degree, took to it kindly in spite of the
pain and discomfort arising from the blisters which the application of the oil over
extensive surfaces gave rise to ; and on seeing that they were benefited, they
sent for their friends not in the asylum and placed them under treatment.
Briefly, then, I have used externally : —

1. As a general application, carbolated oil (1 in 40) rubbed over the whole
body, to promote healthy action of the skin, followed by soap and warm water
ablution.

2. For ulcerated parts, an emulsion of gurjon oil and lime-water (1 in 3),
applied by means of cotton- wool and bandages as well as by friction.

3. For anaesthetic parts and tubercular growths, the application of cashew-nut
oil.

Internally, chaulmogra oil in 5-minim doses, in combination with bicarbonate
of soda 5 grains and peppermint-water 1 fiuidounce.

For a time I used gurjon oil both externally and internally, as recommended
by Dr. Dougall ; but I was obliged to give up its internal administration in con-
sequence of its ill effects upon the digestive system. In some cases it aggravated
the symptoms of indigestion, which is invariably present in leprous subjects, whilst
in others it gave rise to diarrhoea, and I did not consider it desirable, to weaken
the strength of the patients by continuing its administration when we have a
much better remedy in chaulmogra oil, especially as the weaker patients were
liable to attacks of diarrhoea and dysentery.

As an external application, however, gurjon oil is very valuable in the treat-
ment of chronic leprous ulcers, which heal rapidly under its action, and I do not
remember seeing in any single instance the cicatrices open out when it has been
discontinued, although fresh ulcers may break out in other parts of the limbs,
which are similarly healed under its use ; and as a proof of its efficacy, it may be
stated that the patients always asked for more of this emulsion than the quantity
they were allowed.

Gurjon oil is, besides, a cheap article of commerce. The advantages of gurjon
oil, then, are the following: —

1 . Its rapidly healing action in chronic leprous ulcers.

2. It softens the skin, and preserves the newly-formed cicatrices from cracking.

3. It prevents the collection of flies.

4. Its efficacy in the treatment of chronic skin diseases.

5. Its cheapness.

In the cashew-nut oil we have a potent remedy for the dispersion of tubercles.
The oil is applied daily over the tubercles until blisters are formed, when it is
discontinued. This causes the tubercles to soften and disappear, discharging in
some cases an ichorous matter, and leaving an open ulcer. To the ulcerated
surface thus formed the gurjon oil emulsion is applied, under which it cicatrizes
rapidly.

The application of the cashew-nut oil has to be repeated again when the skin
has healed until complete absorption of the tubercle has taken place. Care
should be taken not to let it run over the healthy skin or into the eyes.

The cashew-nut oil appears to be beneficial, also, in the anaesthetic form,
applied in a similar way over the surface covered with the anaesthetic patches.

Chaulmogra oil, as an internal remedy, acts as an alterative and stimulant
tonic. Given in combination with carbonate of soda and peppermint-water, it
relieves in the first instance the distressing burning sensation in the stomach aris-

576

Progress of the Medical Sciences.

[Oct.

ing from dyspepsia, and the constant morbid craving for food which lepers gene-
rally complain of ; at the same time it improves the appetite and promotes diges-
tion, and thus leads to the healthy assimilation of food. Some of the patients
who have been in the habit of taking alcoholic stimulants have asserted that they
experienced a similar effect from its use ; and for these reasons, combined with
its not unpleasant taste, they preferred it to gurjon oil. Chaulmogra oil, more-
over, has been found to have a direct influence in causing absorption of the tuber-
cles, as seen in cases where cashew-nut oil had not been applied, and, therefore,
particularly adapted in the treatment of leprosy.

He has used carbolic acid in combination with sweet oil made from ground nuts,
sesamum seeds, and the seeds of the Verbesina saliva, or cocoa-nut oil, in the
proportion of 1 part of the acid to 20 or 40 parts of the oil, as a general applica-
tion to promote healthy action of the skin, and also as a substitute for gurjon oil
when he has not had a supply of the latter ; but it is more expensive and less
efficacious than gurjon oil in healing leprous ulcers.

Iodide of potassium, he has also used with advantage, especially in cases asso-
ciated with a syphilitic taint ; and he believes it promotes the absorption of the
exudation which causes the tubercles.

Diet. — The patients in the asylum received rice and dill (pulse) as their prin-
cipal meal ; mutton once a week, and occasionally fresh fish. Potatoes and some
of the ordinary country beans and vegetables were also allowed, which they cul-
tivated themselves in the asylum grounds; but brinjals (Solatium Melonghana)
and pumpkins, as well as salt fish or meat, were entirely forbidden. — Edinb.
Med. Journ., March, 1883.

Value of Arsenic in Certain Forms of Ancemia.

A very interesting communication, "On the Arsenical Treatment of Leukae-
mia, Pseudo-Leukaemia, and Progressive Pernicious Anaemia, with some Remarks
on the Mutual Relation of these Diseases," is given by Dr. F. "YV. Warfvinge,
of Stockholm, in a recent number of the Nordiskt Medicinskt ArLiv. It ap-
pears that in the space of little more than four years since the Hospital of Sab-
batsberg, in Stockholm, has been open, there have been under treatment in that
institution no less than eleven cases of progressive pernicious anaemia, and the
same number of pseudo-leukaemia, but only two of leukaemia, thus showing that
the two former diseases are relatively common in Stockholm, and that they are
much more common than leukaemia. The two cases of leukaemia, seven cases of
pseudo-leukaemia, and seven of progressive pernicious anaemia were treated with
arsenic by Dr. Warfvinge with the following results. One of the cases of leukae-
mia was of a slightly advanced lymphatic form, and the patient was able to leave
the hospital after an arsenical treatment of three months' duration (internally and
by injection). He presented all the appearances of perfect cure: the lymphatic
glands had returned to their normal dimensions, and the number of white glob-
ules was reduced to the ordinary proportion. The other case was of a very
advanced splenic form, with an enormous spleen, and the number of white glob-
ules was equal to the red ones. The spleen was considerably reduced in size
under an arsenical treatment of twelve weeks' duration, the number of white
globules was reduced to the proportion of one to ten, and the general health
improved at the same time. But the cure was slow, and was only a little ad-
vanced when the patient, a feeble girl, sixteen years old, wished to return home.
A few injections of Fowler's solution, made in the spleen towards the end of
the treatment, were perfectly innocuous.

In the cases of pseudo-leukaemia, the arsenical treatment, which lasted only a

1883.]

Medicine.

577

few days, was nearly ineffectual in two instances, one of the patients not wishing
to remain in the hospital, and the diagnosis in the other being made only a few
days before death. In the remaining live cases the result was more favourable.
In one of them, in which iodide of iron had been ineffectually administered, and
the cachexia and marasmus had reached an extreme degree, the arsenical treat-
ment for five weeks produced a remarkable, progressive improvement. At the
end of this time the patient presented the appearance of excellent health, had
a voracious appetite, very good muscular strength, the spleen was normal,
and there were only insignificant remains of hypertrophy of the glands, and,
besides, the number of red corpuscles had increased. Unfortunately, six months
after the patient had gone home from the hospital into the country, where he
lived, he had a relapse which ended in death. In another case the arsenic also
produced a remarkable effect on the hypertrophy of the glands. This was par-
ticularly the case after arsenical injections into the glandular parenchyma, the
effect of which was very striking, the diminution of the swellings being rapid and
considerable, but confined to the glands which were injected. The patient, who
suffered all the time from asthma, had occasionally severe attacks of suffocation,
and died in one of them, caused, as was shown at the autopsy, by the pressure
of the mediastinal glands, which were much swollen and had not undergone re-
duction like those which were reached by the injections. In two other less severe
cases of lymphatic pseudo-leukaemia the beneficial effect of the arsenic was un-
questionable ; the use of this remedy for from three to five months produced a
slow diminution of the swellings, and such a decided amelioration of the general
health that the patients on their discharge from the hospital appeared perfectly
well. In the fifth case, a lymphatic pseudo-leukaemia with marked hypertrophy
of the glands of the neck and mediastinum together with general prostration,
the internal use of arsenic reduced the glandular swellings and brought about a
satisfactory general condition, which has lasted for a year.

Of the cases of pernicious progressive anaemia, one rapidly became worse for
a week during which iron was administered : the anaemia and cachexia had
decidedly increased, and the number of red corpuscles had diminished ; but after
the employment of arsenic there was uninterrupted improvement, which was so
well marked that at the end of two months the patient, being regarded as cured,
ceased to take the arsenic, but on the next day after its discontinuance he was
attacked with violent acute nephritis terminating in death. The autopsy proved
the total absence of the ordinary signs of pernicious anaemia. In another case
the patient came to the hospital almost in a dying state, and died in six days in
spite of arsenical treatment ; but it appeared that at an early period of the affec-
tion there had been a decided improvement- on two occasions under the use of
small doses of arsenic. In the third case iron had been unsuccessfully employed
together with other tonics, but on the administration of arsenic there was a con-
tinuous improvement. The red globules in three weeks had been increased
threefold, and at the end of four months they were eight times more numerous ;
but two months afterwards there was a relapse, which again yielded to a fresh
employment of arsenic, and health was restored, at least for nearly a year, dur-
ing which Dr. Warfvinge occasionally saw the patient. In the fourth case the
symptoms grew worse under the use of iron, but wrhen arsenical treatment was
adopted there was a gradual improvement : the health returned, and the number
of red corpuscles was quintupled. But there was a relapse at the end of about
seven months, and arsenic was again employed: health was again restored, and
the red corpuscles were increased in number; a persistent diarrhoea, however,,
compelled the discontinuance of the arsenic, and the patient died from weakness.
In the fifth case the maladv was increased under the use of iron, and the patient
No. CLXXIL— Oct. 1883. 37

578

Progress of the Medical Sciences.

[Oct.

■was at the worst when arsenical treatment was begun, but from that time there
was marked improvement : the patient was able to leave his bed at the end of
five weeks, and the blood was two-and-a-half times richer ; when he left the
hospital the number of red corpuscles was about four times more than at the
beginning of the treatment. In the sixth case, which was less advanced, iron in
large doses produced no effect, but after only eight days of treatment by arsenic
the patient began to improve, and presented the appearance of health at the end
of five weeks, the number of corpuscles being tripled. In the seventh case the
result of the arsenical treatment was equally favourable : the health of the patient
was remarkably improved after two months and a half of treatment, and the
number of red corpuscles was largely augmented. It appears, however, that the
patient died abroad, probably from a relapse. Dr. Warfvinge adds that two cases
of pernicious anaemia are still under his treatment, and are slowly but uninter-
ruptedly improving.

Dr. Warfvinge remarks that the fact of these three maladies — pernicious
anaemia, leukaemia, and pseudo-leukaemia — being equally benefited by the use
of arsenic seems to show a certain degree of relationship between them, and in
proof of this position he passes in review the principal S3 mptoms presented and
the anatomical and pathological changes, particularly insisting on the changes in
the blood. Although the three diseases exhibit certain points of difference, there
is yet a character common to them all, namely, the diminution of the number of
red corpuscles, with a modification of their form and size, the diminution depend-
ing less on the decrease in the formation of new corpuscles than on the abnormal
destruction of the existing corpuscles. Dr. Warfvinge regards the alteration in
the blood as the primary cause of these maladies, and he considers as secondary
affections, caused by dyscrasic irritation, not only the changes in the spinal cord,
but also the hypertrophy of the lymphatic glands and the spleen, and the lymphatic
neoplasms in various situations. The alterations observed in the spinal cord, well
known in leukaemia, he has also found in all the cases of pseudo-leukaemia and
pernicious anaemia which have been examined after death, and he regards these
alterations as common to the three affections, in all of which, moreover, there are
anaemia with cachexia, a disposition to hemorrhages, especially of the retina,
oedema in various parts and transudations, and fatty degeneration of different
organs, especially the heart. The dose of arsenic employed by Dr. Warfvinge
was four drops of Fowler's solution given two or thee times a day, and four drops
of the same daily when used as an injection. — Med. Times and Gazette, Aug. 4,
J883..

SURGERY.

Operative Procedures in Diseases of the Lungs.

Dr. Bull,, of Christiania, in a recent paper reports an interesting case bearing
■on this subject. He also gives a brief review of the literature relating to the
operations hitherto performed in diseases of the lungs, together with some ob-
servations on the indications connected with the opening of tuberculous cavities,
and he draws attention to some new possibilities of limited expiratory expansion
of the pectoral wall. The case was that of a man, twenty-nine years old, who
entered the State Hospital of Christiania, exhibiting all the signs of advanced
pulmonary tuberculosis, such as hectic fever, violent cough, abundant muco-
purulent expectoration, emaciation, and anaemia. In the first, and partly in the

1883.]

Silrgery.

579

second left intercostal space, external to the left sternal border, there was ob-
served during the fits of coughing a considerable and clearly limited expansion
of the pectoral coverings, which circumstance was not observed in tranquil breath-
ing. This limited expiratory expansion was considered due to a superficial cavity
adherent to the thorax, and, perhaps, ulcerated by the pleural adhesion.

Viewing the possibility of the suspected cavity offering an advanced process
of ulceration; of the secretion, incompletely expectorated, flowing into the
neighbouring bronchi ; considering that the fever and the cough were partly
relieved by the opening of the cavity externally by means of drainage and dis-
infection, and that the expiratory expansion in front might perhaps indicate a
commencing perforation of the thoracic wall; — taking all these matters into con-
sideration, it was determined, with the consent of the patient, to try the operation.
This was accordingly performed, and after the perforation of the thoracic wall
the finger could be introduced into a small empty cavity, limited on all sides by
smooth walls, and the base of which was formed by a solid elastic tissue. There
was no sound of air entering or going out. The day after the operation, during
a fit of coughing, there was a sudden discharge by the wound of a liquid like
that of expectoration, and this discharge continued abundant, but without relief
to the patient, and death ensued in six days. On post-mortem examination the
left lung was found to be separated almost entirely from three to four centimeters
from the thoracic wall, and there were only a few filiform adhesions with the
upper parts. There was fibrinous pleurisy and a little pus in the pleural cavity.
At the apex of the lungs there was a large superficial cavity. In other respects
in both the lungs there were the usual indications of phthisis.

The differential diagnosis between a cavity and a pneumothorax in cases such
as the above cannot be made with certainty, and considering the possibility of
mistake, Dr. Bull advises that pulmonary operations should always be performed
with the aid of antiseptics, so that if the incision reveals a pneumothorax the
wound may then be closed and the operation be regarded only as " diagnostic."
Dr. Bull has found in medical literature the records of nineteen cases in which
the opening of pulmonary cavities has been undertaken. Five of these, how-
ever, are imperfectly reported, or the diagnosis was too doubtful to be of any
service. Of the rest of the cases, two were instances of bronchiectatic cavities,
one was a case of bronchiectatic cavity and a cavity consecutive to pneumonia,
five were cases of pulmonary abscess, three of pulmonary gangrene, two of tuber-
culosis, and one of echinococcus of the lung. The results of the operations were
as follows, viz. : Cases perfectly cured, two ; very marked improvement, two ;
more or less relief, seven ; no ill consequences, one ; cases made worse, two. As
to the tuberculous cavities, experience is almost entirely wanting as to the effect of
artificial pulmonary fistulae, and it belongs to the future to demonstrate whether
an operation of that kind is. more dangerous in phthisical patients ; but even when
this proceeding might appear to be without danger, it should not be performed
at a too advanced period of the disease. — Med. Times and Gazette, July 14, 1883.

Ulcer of the Duodenum.

In a recent number of the Medizin. Jahrbucher (1883, lift. L), is an ex-
haustive paper on this subject 'by Dr. Ohvostek, of Vienna, in which he brings
out the following points in its history: —

1. Pathogenesis and Etiology. — The upper portion of the duodenum, in which
the perforating ulcer most often occurs, is more directly under the influence of
the acid contents of the stomach which play an important part in the pathological
anatomy of the affection. The conditions for the origin of duodenal ulcers are

580

Progress of the Medical Sciences.

[Oct.

therefore very similar to what we believe to be true in originating round ulcer of
the stomach, viz., the action of the gastric juice on a circumscribed portion of
the duodenal wall, in which, by some circulatory condition, either by thrombosis
or embolism of the small arteries (Virchow), or by some trouble in the venous
circulation (Miiller, Virchow, Kindfleisch), an extravasation of blood takes place
in the mucous membrane and submucous tissue, or, according to Klebs, by
ischsemia following spastic contraction of the bloodvessels. The experiments of
Panum have shown that obstruction of the calibre of the small arteries can pro-
duce these ulcers, and Miiller has shown experimentally that obstruction to the
circulation in the smaller branches of the portal vein can produce them. More
recently Bottcher has sought to explain them as being due to a fungoid origin,
and Hlava found, in one case, an ulcer the inflammatory appearances of which
led him to believe that it originated in this manner. Finally Aufrecht found
that by injecting cantharidin into rabbits an ulcerative process was set up in
the mucous membrane of the stomach, with well-marked hyperaemia and capil-
lary stasis. From this Aufrecht concludes that ulcers of the stomach are not
due to a primary hypera3mia, but to a primary circumscribed gastro-adenitis.
That they may be both due to the same cause is quite probable from the fact that
in 237 cases of round ulcer Lebert found them together twenty-four times.

Perforating ulcer occurs much less frequently in the duodenum than in the
stomach. In 79 cases of ulcer Itokitansky found it six times; Trier found it
twenty-eight times in 261 cases, and Lebert found not a single one in 60 cases
uncomplicated by round ulcer of the stomach. Chvostek has been able to find,
in medical literature, since 1865, only 50 cases uncomplicated with round ulcer
of the stomach. He himself has seen only seven such cases, one of which had
an ulcer of the cardia.

The greater number of cases seem to occur between the ages of thirty and sixty
years. In 47 cases 26 per cent, occurred before the age of thirty years, 56 per
cent, between thirty and sixty. Perforating ulcer of the duodenum occurs much
more frequently in males ; in 64 cases observed by Kraus, 58 were in males (10 : 1);
and Trier found in 54 cases, 45 in males, and 9 in females (5:1). Of Chvostek' s
8 cases, only 1 was in the female. The general strength and occupation of the
individual seem to have no influence in the etiology of the affection. Chlorosis
is not so frequently a cause as in ulcer of the stomach. Hunger and want are
not frequently causes except when they suddenly come upon an individual accus-
tomed to better circumstances. Alcoholism, especially in the anorexial form, may
be a cause.

There is no doubt that extensive burns of the surface of the body frequently
cause perforating duodenal ulcers. In 125 cases of intense burn, Holmes found
ulcer of the duodenum in 16 cases, and ulcers of other portions of the intestinal
canal in 2 cases. Stokes found several ulcers of the duodenum and stomach in
one case of severe burn. According to Mayer, the ulceration occurs in seven to
fourteen days, and twice as frequently in females as in males. In 8 cases col-
lected by Chvostek the shortest time in the male was two days after the injury
(2 cases), and the longest seventeen days (1 case). The shortest in the female was
two days (1 case), the majority occurring in ten days and upward. Lardier has
reported 2 cases occurring during erysipelas. In a few cases foreign bodies cause
perforating ulcers of the duodenum. Malherbe found, in a case of pemphigus,
three small ulcers with consecutive peritonitis ; Lignerolles observed ulcers of the
stomach and duodenum in a case of. acute pemphigus, and Barth in one of pella-
gra ; and Ebstein found, in a case of trichinosis, a perforating ulcer of the
stomach, the end being hastened by perforation. A certain predisposing cause
exists in diseases which directly or indirectly affect the circulation in the duodenum.

1883.]

Surgery.

581

a. First those which interfere with the portal circulation in the liver, as cirrhosis
of the liver, and cancer of the liver, peritoneum, and pancreas, b. Heart dis-
eases causing- venous engorgement, followed by stasis in the portal radicles, and
emboli in the duodenal vessels, c. Chronic pulmonary troubles, especially
tuberculosis. Billroth is inclined to think that these cases are, in many instances,
of septic origin, especially where the ulcer comes on after an operation, as is
sometimes the case. There is a marked tendency to a second ulceration at the
site of an ulcer which has cicatrized ; a previously existing ulcer also predisposes
to the formation of a new ulcer in its vicinity.

Pathological Anatomy. — As a rule there is only one ulcer, seldom two or
more. In 58 cases, collected by Chvostek, a single ulcer was found thirty-nine
times, two ulcers were found ten times, three and four ulcers were found three
times each, and more than four occurred three times. Its most frequent seat is
in the superior part of the transverse portion of the duodenum. It is generally
round or slightly oval, and from two-fifths to three- fifths of an inch in diameter,
though it may be larger. When healing and cicatrization take place, stenosis
may result, varying from a very slight degree to almost complete closure of the
bowel, with dilatation above the strictured portion, and the setting up of a chronic
catarrhal process. A large stenosis, involving almost the whole thickness of the
bowel, may cause thrombosis of the portal vein, as in a case reported by Frerichs.
The ulcerative process may involve the bloodvessels, erosions of the gastro-duode-
nalis, pancreatico-duodenalis, and other vessels having been reported. In some
cases the whole thickness of the intestinal wall is involved, and blood escapes into
the peritoneal cavity. Chvostek has collected 23 cases in which this occurred, and
in these cases, besides the hemorrhage into the peritoneal cavity, a circumscribed
peritonitis is set up ; this, however, may take place without complete perforation.
Besides this the inflammatory process may cause adhesions between the duodenal
wall and neighbouring organs, and fistula? or abscesses may result.

Symptoms. — The affection may remain latent and only be discovered when
some other disease has carried off the patient, or it may be first discovered when
peritonitis is set up, or the patient may die suddenly from hemorrhage due to
erosion of a bloodvessel. Of 63 collected by Chvostek, death occurred from
perforation in 27 cases, from hemorrhage in 14, exhaustion in 6, pyloric stenosis
in 2, 1 each in suppurative pylephlebitis, peritonitis of unknown cause, peritonitis
from perforation of a round ulcer of the stomach, tuberculosis, paralysis, aortic
aneurism, cerebral syphilis, coma after severe burn, stricture of the intestines
after peritonitis, and from erysipelas in 2 cases.

According to Krauss, in one-fifth of the cases collected by him of perforation
or hemorrhage there was no noticeable pain. There is, however, even when
there is no positive pain, a sensation of pressure and uneasiness in the epigastrium,
especially after taking food. In other cases the pain may be very severe, and of a
constant gnawing character. Sometimes there is intense cardialgia coming on at
a variable time, from half an hour to five hours after eating. Krauss has found the
report of a case in which cardialgia after eating was a prominent symptom, having
lasted for seven years, and was always relieved by a glass of brandy, though per-
foration and death ultimately occurred. The cardialgia [more properly enteralgia],
after lasting for some time, may end in an attack of vomiting of partially digested
food. Vomiting, however, seldom occurs in a case of perforating ulcer. Chvostek
found it only thirteen times in 48 cases. In one case, recorded by Lebert, there
was stercoraceous vomiting. The locality of the ulcer seems to determine the
vomiting in great part ; it more often occurs when the ulcer is situated near the
pylorus. The pain is usually referred to the epigastric or right hypochondriac
region, and is occasionally more violent at night. In chronic cases there may be

582

Progress of the Medical Sciences.

[Oct.

periods when the patient feels quite easy for some time, and then the pain seems
to return with increased intensity. In the opinion of Krauss a continual pain, as
cardialgia, is highly diagnostic of perforating duodenal ulcer. In many cases an
uncomfortable sensation is produced by the slightest pressure, even of the clothes
upon the abdomen.

Dyspepsia is not a prominent symptom in these cases ; usually there is only the
uncomfortable sensation in the epigastrium and right hypochondrium after eating.
Chvostek agrees with Krauss that constipation is more common than diarrhoea in
these cases. In his eight personal observations diarrhoea was present in one only.

Icterus is an infrequent symptom, and when present is due to catarrhal
duodenitis and subsequent occlusion of the bile-ducts by the catarrhal products.
Krauss has found it reported in two cases, in one of which the catarrhal process
had extended to the gall-bladder through a choleo-duodenal fistula. In Chvostek's
8 cases icterus occurred twice, there being a suppurative pylephlebitis in one case.

Profuse bleeding occurs in about one-third of the cases of perforating ulcer.
Blood may be vomited or may pass in the stools. The hemorrhage is not unfre-
quently the direct cause of death. Dyspnoea and orthopnoea occur in ulcer of the
duodenum as well as in gastric ulcer. In a case reported by Lebert so much wind
accumulated under the diaphragm, from perforation, that pneumothorax had
been diagnosticated. In chronic cases the patients gradually emaciate, lose
strength, and acquire an earthy colour.

Diagnosis. — The diagnosis of duodenal ulcer is especially difficult. The
symptoms are so similar to those of gastric ulcer that it is difficult to diagnosticate
between them. A great point is to locate the pain definitely. The pain seldom
occurs when the stomach is empty, but comes on after the ingestion of food. In
a case diagnosticated by Chvostek during life, the pain came on regularly two
hours and a half after breakfast, and three hours after dinner, and passed away
after taking wine. This he considers a valuable point in the diagnosis, for had
the ulcer been in the stomach the ingestion of wine would have increased it, for,
says he, when the ulcer is in the duodenum the ingestion of the stimulant causes
the pyloric orifice to contract and stop the passage of food outward. When pain
occurs after eating, a diagnosis may be arrived at by seeing the result of full and
spare meals. A spare meal, easily digested, is soon passed into the intestine, and
the pain comes on sooner and lasts a shorter time than after a full meal of less
digestible substances. After severe burns the diagnosis is less difficult, as in this
case we may reasonably expect an ulcer of the duodenum. Duodenal ulcers are
more frequent in males, the opposite is true with gastric ulcers. In ulcer of the
duodenum the pain is less intense and less constant ; colic and pain in the back
are more constant and severe ; vomiting, dyspepsia, and cachectic symptoms are
less marked ; and icterus, some diarrhoea, profuse hemorrhage and perforating
peritonitis are more common than in ulcer of the stomach. Krauss proposes the
administration of arsenic as a diagnostic means, as it would increase the pain of
gastric ulcer. In some cases the diagnosis cannot be made, nor can we diag-
nosticate a gastric ulcer from one of the upper part of the duodenum unless we
can clearly define the seat of pain. Perforating ulcer is diagnosticated from tuber-
culous ulcer chiefly by the constant diarrhoea of the latter, and the pulmonary and
general symptoms.

Prognosis. — The prognosis of these cases is bad, and even if they recover
from the ulcerative process, there is a great tendency to stenosis of the duodenum
or of the common bile-duct, which eventually causes ill-health and death. —
]\Iedizinischer Jahrbucher, 1883, Hft. I.

1883.]

Surgery.

583

Resection of the Intestine.

MM. G. Bouilly and G. Assaky give, in the May and July Nos. of the
Revue de Chirurgie, a critical review of resection of the intestine on account of
gangrenous hernia and artificial anus.

Resection and Circular Suture of the Intestine in Gangrenous Hernia. — In the
ten years that have elapsed since 1873 thirty-six cases of intestinal resection and
suture in strangulated gangrenous hernia have been recorded. Of these there
were 21 cases of femoral hernia, 11 cases of inguinal, and one of umbilical hernia,
the variety not having been stated in the remaining three cases. The opera-
tion was performed 19 times on females, and 5 times on males, the sex not
being specified in the remaining cases.

Uninterrupted recovery took place in 9 cases, 7 cases recovered after the forma-
tion and spontaneous closure of a stercoraceous fistula, making 16 complete recove-
ries. A persistent stercoraceous fistula was formed in one case, artificial anus was
formed in one, and there were 18 deaths, making a mortality of 50 per cent.

M. Bouilly concludes, from an examination of the clinical histories, that resec-
tion of a gangrenous portion of intestine followed by immediate suture of healthy
tissues is not only authorized, but indicated, and may be performed: —

1. When the general state of the patient is such that he can stand the ope-
ration with the prolonged administration of the chloroform, or where there is
not a strong probability of a mortal termination by syncope, shock, vomiting,
or pulmonary congestion.

2. When the close examination of the hernia and the actual nature of the
accident enable the operator to reject the existence of general peritonitis or other
grave complication.

3. When the operator is certain that no fecal matter has escaped into the peri-
toneal cavity.

4. When the operator believes that he can easily draw out the gangrenous
intestine and mesentery, and resect in healthy portions.

5. When the continuity of the intestine can be established without having any
great difference in the calibre of the resected ends.

The great dangers of the complete operation are: 1. The possibility of rup-
ture, either by its own insecurity, or from extension of the gangrenous process,
and consequent escape of feces ; and 2. The persistence of the strangulation.

Resection and Circular Suture of the Intestine in Artificial Anus. — 29 cases
of enterectomy with enterorrhaphy for artificial anus are given ; 1 7 cases were
successful; death occurred in 11 cases, and failure in 1. In the large majority
of cases (26) the artificial anus was consecutive to gangrenous strangulated hernia.

M. Bouilly thinks this operation is indicated : 1. In cases in which compression,
application of the enterotome, sutures, autoplasty, etc. have not been attended
with success.

2. When, after careful examination, the precise condition cannot be made out.

3. AVhen the operator recognizes an abnormal position of the intestinal extremi-
ties or superposition, or crossing at a distance from each other, or a marked dif-
ference in the calibre of the two extremities, or several perforations at the same
point.

4. When there exists an irreducible prolapse of one extremity of the intestine ;
still more if both extremities be prolapsed.

5. When there is an extensive prolapse of mucous membrane with or without
invagination of the subjacent portion of the intestine.

6. When the operator has recognized an artificial anus without a spur-like
projection between the two extremities, and accompanied by so large a loss of
substance that a suture of the borders of the opening cannot close it.

584

Progress of the Medical Sciences.

[Oct.

Resection of the Intestine.

Dr. Teresino Prati gives the history of a case in which he resected 2f
inches of intestine. When the case was seen the diagnosis of strangulated left
crural hernia, enter o-epipi 'ocele, which teas in all probability f/angrenovs. was
made. The woman was set. Gl ; in her 1 2th year she had had inguino-crural hernia
of the left side, and in the 1 7th year had umbilical hernia following- delivery. No
cause could be assigned for the occurrence of the present difficulty ; it came on
suddenly during the night. Five days after it appeared she came under observation.
Prati determined to open the sac, reduce, and, if necessary, perform resection.
The patient was chloroformed, the salicylate spray used, the parts washed with a
disinfectant solution, and an incision of about 3| inches in length made along the
greatest diameter of the tumour and parallel to the inguino-crural fold. The sac
was found filled with sero-sanguinolent fluid, of which it was emptied, and it was
then found that a portion of the peritoneum was included in the hernial sac. The
intestine was of a dark slate colour, oedematous, and distended with gas. It
was also found that there was an adhesion of the intestine to the neck of
the sac, which it was impossible to rupture safely. A further examination
revealed a large ulcer in the non-mesenterie portion of the circumference of the
intestine which had been caught in the neck of the sac. The strangulated por-
tion of the intestine measured about ll inch, was oedematoue, slate-coloured,
and contained the ulcer already mentioned. Fearing that, if the intestine was
returned in that manner, there would be perforation and escapes of fecal matter
through the ulcer, Prati resected 2f inches. Excision of the margin of the ulcer
and subsequent suture were not feasible in this ease, as a large part of the lumen
of the intestine was destroyed. The patient died twenty-eight hours after the
operation, apparently from shock.

Prati draws the following conclusions regarding resection of the intestine : 1.
Intestinal resection is a rational operation. 2. One may resect a small portion of
intestine without completely disturbing the digestive functions. 3. In performing
the operation the resected portion must extend into healthy tissues. It is ex-
tremely important that the peritoneal surfaces unite by first intention, and in
order that this may be brought about, healthy tissues must be brought into appo-
sition. 4. The indications for the operation are carcinoma, epithelioma, and
other intestinal tumours, fibrous or cicatricial stenosis, and gangrene from stran-
gulation. 5. The patient maybe fed per orem with liquid food, or rectal alimen-
tation should be employed No solid substance should be allowed to pass the
intestinal wound. 6. It is certain that the patient, in the case reported, died of
shock. — Annali Univers. di Med. e Chir., June, 1883.

In g u in o-properito neal Hern ia .
Dr. Max Oberst describes a case of this form of hernia which was operated
upon in Volkmann's clinique at Halle, in June last. A man, aged 25, had had
a scrotal hernia on the left side for eight years, for which he wore a truss.
Twenty-four hours before admission to hospital it had come down in consequence
of a severe lifting effort, and resisted all attempts at reposition. On admission,
he was found to have a left scrotal hernia of considerable size, and there was
noted a globular bulging of the abdominal parietes above, and external to the
external ring. The scrotal hernia was easily reduced by taxis under chloroform,
but immediately returned when the pressure at the ring was removed. "When
the hernia was reduced the swelling above noted was markedly increased, dimin-
ishing again as the hernia was allowed to descend again into the scrotum. Diag-

1883.]

Surgery.

585

nosis was made of " Hernia inguino-properitonealis," and as the symptoms were
not urgent, the scrotal hernia was reduced, and a bandage applied to retain it in
position. Next day the patient was much weaker, complained of pain, and
suffered from meteorism and stercoraceous vomiting, and it was found that the
hernia had slipped down beneath the bandage. Herniotomy was then performed,
and a small atrophied testicle was found lying in the canal beside the loop of
bowel, showing the hernia to be a congenital one. The external ring was found
to be wide, and the bowel was reduced easily without enlarging the opening, but,
as before, came down again whenever pressure was removed. Upon clraAving
down the intestine so as to permit further digital explorations of the canal, it was
found that the gut had not been returned into the abdominal cavity at all, but
into a wide space extending between the peritoneum and the overlying tissues
towards the anterior superior spine of the ilium, and communicating directly with
the sac through the external ring. This cavity communicated with the abdominal
cavity by a small, tight, well-defined ring, which was found to be firmly con-
stricting the protruded loop of bowel. When this ring was dilated with the tip
of the finger, the bowel was easily replaced in the abdomen, passing away for
the first time with characteristic " slip and gurgle." The wound was allowed to
heal by granulation, the edges of the sac being stitched to the edges of the
external wound, and the patient made a good recovery.

The following references on the subject are given in Dr. Oberst's article :
Kronlein, in v. Langenbeck' s Archio, Bd. xxv., and Archiv f Klin. Chir., Bd.
xix. and xxii. ; Neuber, in v. Langenbeck'' s Archiv, Bd. xxii. ; Rossander, in
Hyg-eia, Jan. 1881; Trendelenburg, in Verhandl. d deut. Oesellsch. f. Chir.,
x. ; Kongress and Boiling, in Berlin Klin. Wochenschr., 1882, No. 26.

The special features of this form of hernia are in the description of the case
given above ; one feature generally noted in such cases is that the symptoms of
strangulation are not urgent. In 20 out of 28 recorded cases the hernia was of
the congenital form.

The cause of this peculiarity in the congenital form, according to Trendelen-
burg, is the persistence of a cavity which must exist at a certain stage in the
descent of the testis ; another instance of arrested development. In acquired
cases, according to Kionlein, the cause is mechanical, the pressure of a badly
fitting truss or repeated attempts at taxis forcing the internal away from the
external ring, and dilating the sac or canal into the pouch between the layers of
the parietes.

Dr. Oberst suggests that when the condition is recognized, the internal ring
might be dilated with the tip of the forefinger, pushing the skin of the scrotum
before it up through the external ring, except, of course, where the condition of
the bowel is doubtful. If this fails, herniotomy, as in his own case, is necessary,
and if that also failed, then Trendelenburg's method might succeed, viz., lapa-
rotomy and reposition of the bowel by traction from within. — Glasgow Med.
Journal, July, 1883.

Removal of Large Renal Tumour by Abdominal Section.

Dr. Henry G. Rawdon reports the case of a female child, a3t. 1 6 months,
first seen on August 31, 1882. The mother stated that she first observed a* swell-
ing on the left side about two months previously, and that, coincident with the
enlargement, she noticed her becoming fretful and poorly, and getting much
thinner.

The child had, for a few weeks prior to admission, been brought as an out-
patient; during that time the tumour had increased, but not to any marked
extent.

586

Progress of the Medical Sciences.

[Oct.

The tumour, which was easily made out, occupied the entire space between
the left costal cartilages and the crest of the ilium. It extended at least an inch
beyond the median line, and could be felt in the lumbar region. The tumour
was to a certain extent movable, and on palpation gave the impression of a solid
elastic growth of a globular shape, with a generally smooth surface, but with two
or three prominences upon it. The urine was ascertained to be free from blood
and albumen. On September 2, under antiseptic precautions, an incision was
made in the linea alba, extending about two and a half inches above and an inch
below the umbilicus. As soon as all bleeding had ceased, the peritoneum was
divided and the tumour reached. The descending colon passed downwards over
the tumour, which was very intimately embraced by it, the peritoneal attachment
of this intestine being so connected with the tumour that it could only be sepa-
rated with great difficulty, from fear of laceration.

When the growth was freed from its connections, the pedicle, which included
the renal artery and veins, was securely tied with carbolized silk. The ureter —
together with some cellular adhesions — was separately ligatured.

The pedicle was now divided at a safe distance from the ligatures, and, after
enlargement of the external wound, the tumour was removed. During the ope-
ration there was an unavoidable loss of a small quantity of blood — probably not
more than an ounce — from tearing adhesions connecting the colon to the tumour
in the first instance, and its cellular attachments. Before putting in sutures and
closing the wound, the cavity in which the tumour lay in the lumbar region and
the pelvis was carefully sponged out, and no oozing was noticed.

The child was much collapsed for two hours, but then slowly rallied fairly
well. In the evening she seemed free from pain, was able to take a little nour-
ishment, and appeared to be doing as well as could be expected, but in the night,
fifteen hours after the operation, she sank somewhat suddenly.

An examination was made next day. The peritoneum was found to contain
about an ounce of altered blood, or sanious serum. The ligatures were found to
be secure ; the small oozing must, therefore, have come from torn adhesions.

The cause of death was not clear, but suspicion pointed to commencing septi-
caemia or peritonitis, or possibly it may have been due to the antiseptic (t. e.,
carbolic spray and dressings).

The tumour was decidedly carcinomatous ; it was globular in form ; the prom-
inences upon it were more rapid growths of the same kind, only more friable and
softer. Internally it contained several cysts, inclosing a deep straw-coloured
fluid. It weighed sixteen and a half ounces. No trace of the true renal struc-
ture remained. — Liverpool Med.-Chir. Journ., July, 1883.

OPHTHALMOLOGY AND OTOLOGY.

Dilute Solutions of Eserine in Weakness of the Ciliary Muscle.

Dr. John C. Uhthoff contributes a paper to the Brit. Med. Journ., July 7,
1883, on this subject. The therapeutic use of weak solutions of eserine was first
pointed out to him by Mr. Bader, about a year ago ; and since then he has made
trial of them in a large number of cases of failure of accommodation, and with
very considerable success. He generally orders a ^ grain solution to be used
three times a day, and he warns the patient that he may experience some unplea-
sant twitching of the eyelids, and possibly a little dimness of sight, for a short

1883.]

Ophthalmology and Otology.

587

time, after applying the drops. In some cases benefit has accrued at once, has
continued as long as the drops have been used, and has lasted for a varying period
after their discontinuance. In some, the improvement has passed off, and I have
been obliged to increase the strength of the solution in order to continue the effect.
In other cases, and they have been few, no benefit whatever has resulted.

He has found these solutions more especially beneficial in two classes of pa-
tients.

The first and chief class consists of cases of slight hypermetropia in young adults,
where the error of refraction has caused no defect of vision until — through some
failure of general health, or perhaps from overtaxing the eyes by an excess of near
work — the power of accommodation has failed, and then there has arisen an array
of troubles sufficiently well known ; headache after near work, and inability to con-
tinue at it for any length of time, especially if by artificial light, being chief among
the number. In such patients the treatment is particularly valuable, and may
keep the power of near vision at its normal standard, until with rest and an improve-
ment of the general health, the muscle recovers its normal power. As an exam-
ple of this class he mentions the case of a young lady, who was sent to me suffer-
ing from all the troubles incident to the presence of an accommodating power
insufficient to compensate for the slight amount of hypermetropia (1 D) which
existed. Her sight had been good until a few months before coming to me, when
she thought she strained her eyes by doing an unusual amount of near work by
artificial light. Her far vision was good, and she could read D 0.5 Snellen
for a short time with ease. The use of 5'q grain solution of eserine three times a
day caused immediate improvement, and at the end of a fortnight she wrote to
me saying that she was able to paint and read steadily and with comfort for a
much longer period than she had been able to do for six months before.

Secondly : patients with high myopia, even when fitted with suitable glasses,
are sometimes unable to use them with any comfort for near vision, this being
often in great part due to the feeble accommodating power such myopic eyes pos-
sess. These persons will speak gratefully of the benefit they derive from the use
of weak solutions of eserine.

Trephining the Pyramid of the Petrous Bone.

Gluck attempted on the cadaver to ligate the internal carotid in its canal,
and succeeded in fifteen cases in chiselling out the artery in its whole course,
without wounding the jugular vein or the transverse sinus. He therefore believes
that, in conditions which demand trephining of the mastoid process, we can gain
a more radical cure by resection of the pyramid of the temporal bone with the
chisel. The author subsequently had an opportunity of proving in a case that
such an operation was feasible. A patient with chronic suppuration of the middle
ear was suddenly attacked, after previous and repeated hemorrhage from the right
ear, with viole'nt headache, sudden fainting, convulsions, and amaurosis, which
were followed by a soporous condition, facial paralysis, and paralysis of the right
arm. A collection of pus between the dura and pia maters, as a result of the otor-
rhea and erosion of the internal carotid, appeared to be the probable condition,
and was thus diagnosticated. After chiselling away the posterior wall of the
meatus, a portion of the mastoid process and of the temporal bone, the dura
mater was extensively exposed, as a bluish, tightly-stretched, fluctuating sac.
The dura mater was then opened, whereupon about 60 grin, of thick fetid pus
which had lain between the dura and the pia escaped. The finger could be
pushed up into the cavity as far as the internal occipital protuberance. Death
ensued on the following night. At the post-mortem examination the dura mater

588

Progress of the Medical Sciences.

[Oct.

was found sunken into the slightly concave surface of the brain upon the operated
side, while, its inner surface, from the longitudinal sinus to the base of the brain,
was covered with an adherent layer of pus. The base of the skull was unaltered.
There does not seem to have been any accurate examination of the ear, from
which, however, the disease had its starting-place. — Archives of Otology, June,
5883.

MIDWIFERY AND GYNAECOLOGY.

Extra- Uterine Pregnancy.
Professor A. I. Krassowski records an interesting case of extra-uterine preg-
nancy which he successfully interrupted by means of paracentesis through the
vaginal fornix. The patient, aged 23, had two normal labours. Her third preg-
nancy was recognized as extra-uterine by Dr. I. F. Smolensky, who based his
diagnosis chiefly on the presence of a gradually growing, moderately movable,
painless, ovoid tumour felt in the lesser pelvis through the left half of the vaginal
fornix as well as through the thin abdominal wall. From the rather enlarged
but empty wround, the tumour was separated by an interspace of a finger's
breadth. Having been called to the patient, the author confirmed Smolensky's
diagnosis. He found also that the swelling consisted of two distinct parts : the
anterior (nearest to the abdominal wall) solid, and the posterior soft and fluc-
tuating. The late Professor M. I. Horwitz and Dr. Y. N. Etlinger, consulted by
the author, agreed with him in regard both to his view of the case (tubo-ovanan
pregnancy about the end of the fourth month), and to the urgent necessity of
arresting the further course of pregnancy. Accordingly, a long curved trocar, as
large as a raven's (pill, was plunged into the fluctuating part of the tumour.
About three and a half ounces of a clean transparent fluid escaped, the last por-
tions being tinged with blood. No untoward symptoms followed, except that,
from the third to the tenth day after the operation, there was observed some
oozing of dark thick blood from the uterus. A month later, quite normal cata-
menia appeared. The tumour began to shrink and to become denser, more un-
even, and more movable. Two months after the operation its size was only a
half of the former bulk. The general state of the patient remains quite satisfac-
tory. Professor Krassowski joins Spiegelberg, Schroder. Fi'ankel, and others in
recommending puncture of the ovum in every case of suspected tubal or tubo-
ovarian pregnancy. — London Med. Record, July, 1883.

Metria.

In the Section of Obstetric Medicine at the annual meeting of the British Medi-
cal Association in August, 1883, an interesting and instructive debate occurred
on this subject.

Dr. Lombe Atthill, in opening the discussion, said that the pathology of
metria is still far from being perfectly understood. Two facts alone are admitted
by all who have studied the subject carefully : namely, first, that puerperal
women are liable, under certain circumstances, to be inoculated with septic matter
conveyed to, and deposited in, the vagina by the hands of the attendants, as well
as by other agencies, when, either through carelessness or ignorance, proper pre-
cautions have not been adopted to prevent such an occurrence ; and that the dis-
ease produced by such inoculation is not an unfrequent source of one of the forms

1883.]

Midwifery and Gynaecology.

589

of metria ; secondly, that puerperal women may be self-inoculated by poisonous
matter originating within their own bodies, from the decomposition of blood-clots
formed within the uterus after parturition, or of portions of the membranes or
placenta which have been retained in utero ; the only difference of opinion on
this point being, that Dr. Matthews Duncan and others term the disease thus
produced "sapraemia" — that is, resulting from the absorption of putrid matter —
thus distinguishing it from "septicaemia," or the disease produced by "organisms
which, when conveyed to the blood, multiply indefinitely in it;" while those
which are the product of putrefaction kk do not survive, far less grow, therein."
(Dr. Matthews Duncan on Puerperal Fever, Lancet, Isov. 6, 1880.)

I hardly think that any one will dispute the correctness of the foregoing points ;
they have been established beyond all doubt ; and it is certain that poison, intro-
duced into the system by one of the two ways indicated, is the cause, in the vast
majority of cases, of so-called puerperal fever, whether occurring in private or
hospital practice. But there are many who believe that the whole subject is
summed up in a belief of these very important propositions, and who think that
to go outside of these lines is only to cause difficulty and to create confusion. I
admit this ; but it seems to me that such an argument is almost an appeal ad
misericordiam, and that it cannot be admitted for a moment. I believe that, in
addition to the two preventable forms alluded to above, we have others ; and I
ask the members of this Section to consider whether we have not, in addition to
these, two other forms of metria, which it may not be possible to guard against —
namely : —

1. A form of self-infection, occurring under special conditions, to which I shall
allude by and by, which is not preventable by the adoption of any antiseptic
treatment.

2. An epidemic, highly infectious, form, which spreads by the same means as
ordinary epidemics do.

Before commencing the discussion of these propositions, it is essential to bear
in mind that I entirely concur in the opinion now generally held, that septicaemia,
occurring in a puerperal woman, is not capable of being communicated to another
puerperal patient by any means other than the direct transfer of the infectious
matter to some portion of the mucous membrane lining the genital tract. Septi-
caemia, however, when it attacks a puerperal woman, may be spread by various
agencies, as well as by the hands of the attendant — for instance, by the nozzle
of a syringe, by the use of infected sponges, by imperfectly washed napkins, bed-
linen, etc. ; but not through the medium of the air breathed by the patient. Of
the truth of this I have not the slightest doubt.

You will observe that I have spoken of the two ordinary forms of puerperal
septicaemia as being preventable. It is evident that, with thorough cleanliness,
and the use of antiseptic precautions, septic poison should never be introduced
into the patient's system by the attendants ; further, I believe that it is possible
to prevent self-infection in a healthy woman, by adopting precautions to insure a
good and permanent contraction of the uterus, and by washing out the uterus
whenever we have reason to suspect the existence of clots, etc., in it, with a dis-
infecting fluid. With the former object, I make it a practice to put all patients
in whom a relaxed condition of the uterus exists, on ergot, from the moment
labour terminates, continuing its administration for at least a week. I believe a
relaxed condition of the uterus to be a very common predisposing cause of self-
infection in puerperal women ; it favours the formation of clots in utero, and
ajso, the orifices of the uterine sinuses being left open, the absorption of septic
matter is favoured.

In proof that I do not exaggerate the importance of imperfect contraction of

590

Progress of t n e Medical Sciences.

[Oct.

the uterus, as a main factor in the production of puerperal septicaemia, I may-
point out that I recently saw, in consultation, three patients suffering from this
affection, in all of whom labour had been so rapid that the child was born before
the arrival of the medical attendant ; and it is a well-known fact that relaxation
of the uterus is very liable to follow the too rapid emptying of that organ.

This train of reasoning has led me to believe that imperfect uterine contraction
is one of the causes of the frequent occurrence of septicaemia in unmarried women.
The mortality from septicaemia amongst them is very great, and there is no
doubt but that the great mental distress these poor creatures suffer, interferes
with the recuperative process which should take place rapidly in the uterus after
parturition. The muscular fibres of the organ do not contract as they should ;
the blood-supply, consequently, is not cut off, the mouths of the sinuses remain
open, the denuded placental site, instead of becoming rapidly restored to its
normal condition, becomes unhealthy, and the fetid discharge, which, under
these circumstances, takes the place of the normal lochia, either enters the
system directly through the open mouths of the placental sinuses, or is absorbed
at the site of some fissure in the mucous membrane lining the genital track. This
is one form of puerperal septicaemia which I fear is beyond the reach of pre-
ventive treatment. No antiseptic precautions can prevent its occurrence, no
treatment that I know of will stay its progress. In patients suffering from cer-
tain forms of chronic disease a similar condition is observed, and similar results
follow.

In my opinion, the infection arising from any of the forms of metria to which
I have alluded, cannot be carried by the attendants from one patient to another,
if precautions be adopted to prevent it. And only a year ago I was strongly
inclined to believe that epidemics of so-called puerperal fever would not occur
as long as such precautions were adopted. Those enforced by me among the
pupils attending the Rotunda Hospital were the following: —

1. Students attending the practice of the hospital should not undertake jiost-
mortem examinations, be engaged in dissections, or attend a hospital containing
patients suffering from infectious diseases ; and,

2. Before proceeding to examine any patients, they washed their hands in a
solution of carbolic acid.

During the first six years and a half of my mastership, these sufficed to pre-
vent the occurrence of anything like an epidemic of so-called puerperal lever.
Deaths from septicaemia, especially among unmarried women, from time to time
occurred, but the disease never spread ; in August last, however, the hospital
being at the time extremely healthy, a patient was admitted who complained of
pain in the abdomen, and who vomited constantly, the fluid ejected being
greenish. She stated that she had been in labour for more than twelve hours,
and that, during the whole of that time, she had been vomiting; and it was sub-
sequently elicited that she had been complaining for some days previously, and
also that she had been seen, at the commencement of labour, by some practitioner,
who advised her to go into hospital. The os, at the time of admission, was about
one-third dilated, labour progressed very slowly, and she finally was delivered by
the forceps. Vomiting ceased after delivery for a time, but soon recurred, every
thing swallowed being ejected, with large quantities of greenish fluid. The ab-
domen became tympanitic, the pain intense, matters went from bad to worse,
and she died on the fourth day after delivery. Her appearance strongly resem-
bled that of a patient suffering from typhus fever.

Another patient was admitted on the same day as the last patient, and she lay
for a short time in the bed next to her. The patient's labour also was slow, but
it terminated by the natural efforts. She was attacked with symptoms of acute

1883.]

Midwifery and Gynaecology.

591

peritonitis thirty-six hours after delivery, and almost immediately afterwards we
noticed a very peculiar, almost black, appearance of the face. The course of
the disease was identical with that of the preceding case, but was even more
rapid. The first symptoms showed themselves on the morning of the 29th, and
she died on the 31st.

The disease now spread- rapidly, and so virulent was the epidemic that, out of
twenty-nine women admitted during six days which intervened between the
delivery of the first patient and the issue of the order to refuse admission to all
applicants, eleven women were attacked, and nine died.

The admission of patients being stopped, the wards were thoroughly disin-
fected, the walls lime- washed, the floors washed with a strong solution of chloride
of lime; the cupboards, presses, etc., scoured; the nurses' clothes, as well as
their bedding, being washed and aired, and placed in the hot-air chamber.
Patients were re-admitted on September 12th; and from that date till the ex-
piration of my mastership on November 4th, during which time 118 women were
admitted into the hospital, the health of the patients was excellent, and, I am
informed, continues to be so still. No more successful effort to stamp out disease
than this was ever recorded. This, and the fact that the epidemic was distinctly
imported into the hospital, and that it did not originate in it, are facts as important
as they are satisfactory ; and though the occurrence of the outbreak was a cause
of great distress to me, and though it was a great disappointment that, at the very
close of my mastership, such a misfortune should have happened, still these two
facts lessened the regret I naturally experienced.

Some years previously, a patient suffering from erysipelas of the head and face
was, during the night, sent up to the labour- ward, her condition not having been
detected till she was being undressed. The child's head was in the perineum,
and she could not be sent out. She was at once removed to a separate ward,
and early next morning transferred to a fever hospital ; but though her stay in
the lying-in hospital was so short, several patients were attacked, not with ery-
sipelas, but with so-called puerperal fever, and one died. The disease was limited
to the one ward. I ask you, gentlemen, to consider what the disease attacking these
women was. To me it seems to have been a disease originating by the introduc-
tion into the system of a puerperal woman of the infection of erysipelas, which
infection was modified by the peculiar state of the system and of the blood which
exists in puerperal women, and which, therefore, developed an apparently dif-
ferent disease ; and I am strongly inclined to the belief that outbreaks of so-called
puerperal fever, when it assumes an infectious and epidemic form, are due to the
introduction of the poison of some ordinary zymotic disease into the system of a
puerperal patient, the symptoms being, under such circumstances, totally different
from those occurring in cases of septicemia.

Dr. Thomas Moore Madden said that having been for upwards of twenty
years in practice, and having been for some years connected with the largest
lying-in hospital in Great Britain, I have had some opportunity of gaining expe-
rience on this subject. I have, therefore, no hesitation in saying that, in common
with others who have had similar experience, I am as convinced as I can be of
any fact whatever of the existence of puerperal fever or a specific infectious dis-
ease peculiar to puerperal women. The entity of this disease is in no way affected
by whatever name we may choose to term it ; and whether we speak of it as
puerperal fever, metria, septicemia, utero-peritonitis, saprasmia, or by any other
appellation, its distinct existence remains unmistakable as that of measles, scar-
latina, typhoid or typhus fever, or any other zymotic disease ; although its pre-
dominant symptoms are varied, as those of these diseases also are, at different
periods, and during different epidemics, by the prevailing atmospheric epidemic

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Progress of the Medical Sciences.

[Oct.

constitution, by the general condition of the patient, by the intensity of the sep-
ticagmic intoxication in each case, and by a variety of other modifying circum-
stances.

He regarded it as a zymotic infective disease, prevailing periodically as an epi-
demic, and being, moreover, endemic in some places, under certain circumstances.
It is unquestionable that the disease may result from infection with the poison
of other zymotics, such as erysipelas, scarlatina, and typhus fevers, as well as be
induced by auto-inoculation with septic matter self-generated in the patient's
system, or by hetero- inoculation with septic matter introduced from without.

Amongst the causes of puerperal fever, some reference should be made to
laceration, during labour, of the cervix uteri. This accident, especially where
the injury has been occasioned by the abuse or premature employment of the
forceps before the natural dilatation of the os, is probably a very important,
though generally entirely unrecognized, factor in the modern etiology of puer-
peral septicemia. Under such circumstances, the danger of rupturing the undi-
lated parts is self-evident. And it is equally obvious that thereby is afforded a
ready channel for the auto-inoculation of the patient with any septic poison exist-
ing in the lochial discharge, which may be absorbed through the raw edges of
the lacerated surfaces, and thus give rise to septicaemia. There can be no question
as to the toxic effect of inoculation with even apparently healthy lochial matter ;
and, therefore, much more likely is this to occur when the lochia are in an ab-
normal or vitiated condition, as is so generally the case a few days after difficult
and instrumental deliveries.

The treatment of puerperal fever, he said, must be governed by the predomi-
nant symptom of each case, and depends largely on the prevailing epidemic type
of the disease, which varies widely at different times. Even within the compara-
tively short period included in my own obstetric experience, several changes
have taken place in the prevailing type of puerperal fever in successive epidemics,
and hence in the treatment required. We now seldom, if ever, meet with the
true inflammatory utero-peritonitis, for which, in my student days, mercury with
opium, and free depletion by leeching, were almost invariably prescribed. I well
remember often seeing the puerperal patient's abdomen covered, under such cir-
cumstances, by what the late Dr. McClintock graphically described as a poultice
of leeches. And, I may add, that 1 have still a lively recollection of the benefits
derivable, in appropriate cases, from this line of treatment. Within the last
fifteen or eighteen years, however, I have never seen a case of puerperal lever
in which any form of depletion could be tolerated ; the disease having now, in
common with all others, assumed an asthenic or typhoid form, and like them
appearing more in the character of a septicaemia than of a true inflammatory
malady.

Thus, when, some years after my first acquaintance with the practice of the
Rotunda as a student, I became one of the medical staff' of the same hospital, two
forms of puerperal fever came before me ; one with marked uterine pain and
tenderness and abdominal distension, and the other without any localized pain ;
both accompanied by a low typhoid condition tending to death, and obvicusly
requiring stimulation, and especially the free use of turpentine by the mouth, by
enemata, and by external application in stuping the abdomen. The form of
puerperal fever now most frequently met with is distinctly remittent in its type.
Several cases of this kind have come under my observation in which the fever
was of the tertian character. Still more usually, however, there are daily matu-
tinal remissions. Thus the temperature and pulse in the second week of the ill-
ness often fall each morning to little above normal, and again rise throughout the

1883.]

Midwifery and Gynaecology.

593

afternoon, until in the evening the former has reached 105°, and at the same time
the pulse becomes about 120.

In the treatment of the remittent forms of puerperal septicaemia, our main reli-
ance must be placed in quinine. This should be given in medium doses of from
three to four grains at short intervals of three to four hours, and continued until
the pulse and temperature have been sufficiently reduced, and cinchonism has
been maintained for some days.

I may here repeat that, with very few exceptions, all the cases of puerperal
fever I have recently seen were of an essentially asthenic type, presenting all the
symptoms of so-called malignant puerperal fever or septicaemia, and, conse-
quently, were not suitable cases for any form of depletion ; but, on the contrary,
required the free use of stimulants and nutriment.

Whatever other treatment may be indicated, however, the use, twice daily, of
warm antiseptic intra-uterine and vaginal injections is essential in every case of
puerperal septicaemia. The use of such injections, for the purpose of thoroughly
washing out septic exudations from the cavity of the uterus, is self-evident. But,
at the same time, it should be said that they require to be used with far more
caution than is generally practised. Nor should we ever fail to impress on the
nurse, in such cases, the risk of probably injecting virus into the open uterine
sinuses; or, on the other hand, of forcing the injected fluid through the patulous
Fallopian tubes. I have more than once seen injury caused, in both these ways,
by want of such caution in the use of the ordinary siphon syringe.

Dr. Alexander (Liverpool) said there were two kinds of so-called puerperal
fever ; the first where the disease was in reality erysipelas, typhus or scarlet
fever. In such cases, the epidemic disease modified the conditions of the lochia,
and produced a metria that, in its turn, modified the epidemic disease. In the
other class of cases, the disease always began in the uterus, and was really a sep-
ticaemia dependent on the altered conditions of the uterine contents, produced
by obstruction to the flow of lochial fluid, nervous conditions that relaxed the
uterus, putrid poison introduced from without, etc. The putrid discharge was
absorbed, and poisoned the patient. Acting upon this theory, his treatment had
been, whenever the fever was high, to make the uterus contract by pressure of
the hand on the abdomen, and put on a firm binder. He gave a dose of ergot
and liquor ammonias acetatis, continued every four hours. If the patient's tem-
perature did not soon abate, L e., in a few hours, he washed out the uterus care-
fully once, and continued the former treatment. Since adopting this treatment,
he had had no trouble with puerperal fever. The treatment must be adopted
early.

Dr. Wynn Williams (London) considered those cases only as puerperal
that were due to septicaemia, which might arise either from within or without the
body ; when arising from without, there must be suppuration, such as there was
in scarlet fever, erysipelas, etc. It generally, however, arose from within, due
to the retention of clot or other animal matter becoming putrid. The object,
then, was to destroy the septic matter, which was best done by syringing the
uterus with tincture of iodine, three drachms to eight ounces of water, and con
tinuing the process until the fluid returned of the same colour as before. Experi-
ments on guinea-pigs had satisfied him that iodine and septic poison could not
exist together. A practitioner might surely free himself from all trace of 'septic
poison by placing some grains of iodine in a saucer, and applying a spirit-lamp to
the bottom of, and allowing the fumes to fall over his person.

Dr. A. D. Macdonald (Liverpool) was happy to support the view of Dr.
Wynn Williams that washing the hands with a weak solution of iodine was a
great means of prophylaxis. He had recently attended cases of erysipelas and
No. CLXXII Oct. 1883. 3*8

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Progress of the Medical Sciences.

[Oct.

of scarlatina — using this solution — and having no metria following. A short time
ago, he was called to a case of puerperal fever delivered by a midwife where she,
after warming and using the iodine, as well as having a short holiday, had not
had a bad case. This case illustrated the communication of the contagiuin
through hand-shaking with a nurse who had attended a case of septicaemia.

Dr. Edis (London) thought the whole question of metria was of so much im-
portance to the practitioner, that anything throwing light upon it was of interest.
Prevention was the key-note : not to allow the patient to drift into powerless
labour ; to secure efficient contraction of the uterus and expulsion of all the
decidua; to be scrupulously cleanly in all the appointments of the lying-in room
and in those in attendance there; to avoid all risk of infecting the patient with
any contagion, whether exanthematous or otherwise. If febrile symptoms oc-
curred, the proper course was to wash out the uterus, to sustain the patient's
powers by appropriate nourishment, and stimulants if necessary, and to encourage
rather than check the natural tendency to vomiting or diarrhoea. Quinine and
opium should be given, or iron, as might be indicated. The mere name of puer-
peral fever was merely a comprehensive term to express very many varied condi-
tions occurring in the lying-in patient, and not any specific disease.

Dr. Graily Hewitt, in closing the discussion, said that, although the
speakers had expressed opinions of a different character, there was a general
concurrence on certain important general principles, and that this serious disease
must be considered as not only preventable, but in most instances curable. The
prevention of the disease was secured, first, by prevention of the introduction
of septic matter from without. The autogenetic cases were, lie considered,
common ; and in this class of cases the important point was to raise the health
and strength of the patient, and thus prevent absorption by ensuring active
contraction of the uterus. Mr. Burton's and Dr. Alexander's observations
showed the great importance of uterine contraction in curing the malady. On
this subject, he was pleased to find the treatment found so successful by Dr.
Alexander was identical with that recommended by himself at the discussion on
puerperal fever at the Obstetrical Society of London some years ago. He men-
tioned a case of mental shock producing severe metria, cured by pressure, copious
administration of food, and stimulants. Here the pressure was found sufficient
without intra-uterine injection. — British Medical Journal, Aug. 11, 1883.

Dysm en orrhcea.

Dr. Yedeler, of Christiania, in an exhaustive article on this subject, declares
that ergot is a good remedy in severe cases of dysmenorrhoea, though it has not the
same action in all cases ; the definite indications must be sought, and the history
of each case entered into as far as possible.

Mackintosh first definitely described mechanical dysmenorrhoea, though Capu-
ron, Lisfranc, and Fingerhuth had already mentioned a contraction or stricture
of the cervical canal as a cause of painful menstruation ; and more recently Simp-
son and Marion Sims have still more clearly described it. In some cases no-
thing more than an abnormally small uterine cavity can be discovered to account
for the dysmenorrhoea. These cases of the affection, often intermittent, are very
difficult to recognize.

Yedeler takes issue with Emmet when he says that " every woman, even in
health, will experience at least some degree" of discomfort at the menstrual period :
that she should be entirely free from pain and suffer no inconvenience at this
time is an abnormal condition;" and gives three tables of 252 menstruating
women who came under treatment for various affections. In none of the cases

1883.]

Midwifery and Gynaecology.

595

was there any pain. The first table includes 59 virgins : in only 12 of these wa3
the cervix in its proper position. The remaining 47 had various degrees of flexion.
In 3 the cervix and uterine body were parallel to each other. Of the diseases
for which they came under treatment. 8 "were anaemic. 11 had cardialgia. 3 chlo-
rosis, 3 amenorrhea, and 5 cephalalgia, while others complained of bronchitis,
neuralgia, etc. The second table includes 101 unmarried women. In 36 cases
the axis of the uterus was a straight line, axis normal in 13, anteversion was
present in 14 cases, and retroversion in 9. The uterus was flexed in 65 cases.
Of the diseases for which they came under treatment anaemia was present in 7
cases, cardialgia in 9, chlorosis in 4, and amenorrhcea in 2, besides other affections.
On examination the external os was found to be small in 8 cases. In 19 cases
the uterus was small ; chronic parametritis of the uterus existed in 3 cases, of the
cervix in 6. endometritis in 14, and chronic perimetritis in 4 cases. The third
table embraces 92 patients, married: in 44 the uterine axis was a straight line,
the axis was normal in 15, there were 20 anteversions, and 9 retroversions. The
remaining 47 had more or less flexion. A3 before stated, there was no pain
at the menstrual period in any of these 252 cases, although the axis uteri was
markedly abnormal in 56. From this, says Vedeler, it seems that dysmenorrhcea
cannot be entirely dependent upon flexion or malposition of the uterus.

As to the second assumed cause of dysmenorrhcea : Stenosis of the external os. —
How large should the external orifice be in order to call it normal ? Vedeler
generally uses a Simpson's sound of 4 mm. If his Sims sound of 3 mm. passes
the external orifice with such difficulty that the operator has to employ as much
force as is safe, he calls it a small orifice, and very small when it is no larger than
a large pin-head. The external os was stenosed in 6 per cent, of the 252 cases
given above, in 6 of which the orifice was very small ; yet there was no pain.
Vedeler does not seem to agree with Sinety. that the intensity of the pain depends
on the quantity of the menstrual blood, and the exfoliated mucous membrane ;
if the blood comes slowly and in small quantity, it escapes without causing pain.
Nor does he entirely agree with Lombe Atthiil in saying that it is not unusual to
find a cervical cavity of the size of a pin's head with which dysmenorrhcea is com-
mon.

Sims declares that inflammation of the cervical mucous membrane is a cause
of dysmenorrhcea; but Vedeler's tables show 5 cases of cervical endometritis in
virgins, 12 in unmarried women, and 25 married, in all 42 cases, without pain at
the menstrual period. Vedeler further declares that in cervical endometritis, not
only a large sound may be passed but in many cases the end of the forefinger
may be carried into the cervix.

Cervical myoma and raucous polypi. — These are stated to be causes of dys-
menorrhcea, but Vedeler declares that they are extremely rare. Xot one case was
found in his 252. Further in 5800 patients he has not seen a single case of dys-
menorrhcea which was caused by polypi, and only three caused by cervical myoma.

Vedeler then gives a table of 100 cases of dysmenorrhcea, of which 13 were vir-
gins, 47 were unmarried, and 40 married ; 82 had had no children, 18 had
had one or more. It is seen from the table how commonly dysmenorrhcea and
sterility are associated together. In the 100 cases anteflexion was present in 71
cases, retroflexion in 4. the position was normal in 8. anteversion in 6, and retro-
version in 11. The cervical canal was of normal direction in 20 per cent., and ab-
normally curved in 75 per cent.1 From this it seems that flexions of the uterus,
and especially anteflexion, have a great influence in the etiology of dysmenor-
rhcea, anteflexion being present in 71 per cent, of all the cases. Retroflexion

1 He fails to account for the other 5 per cent.

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Progress of the Medical Sciences.

[Oct.

was present in 4 per cent., anteversion in 6 per cent., retroversion in 11 per cent.,
and the position was normal in 8 per cent.

Only 18 of the 100 cases had had any children. The others were nulliparae. An
analysis of the table shows that the 71 per cent, of anteilexed uteri all occurred
in nulliparae. Of the 4 percent, of retroflexed uteri, 3 per cent, were nulliparae.
Of the nullipara? 9 per cent, had uteri in normal position, 7 per cent, were ante-
verted, and 9 percent, retroverted. From a consideration of these facts Vedeler
concludes that flexions of the uterus have a marked influence on dysmenorrhea,
while he questions the influence of stenosis of the external os, and of endometri-
tis (as far as its mechanical influence is concerned), and believes that the mechani-
cal theory of dysmenorrhea will soon be thought of only as a myth. — Archiv
fur Gynakologie, Bd. xxi. Hft. ii.

Pathology and Treatment of Uterine Myoma.
At the meeting of the Obstetrical Society of London, on July 4th, Mr. Law-
son Tait, during the course of his remarks on this subject, said that the word
"myoma" should entirely supersede the incorrect term " uterine fibroid." The
growth of ordinary myoma was limited to the period of sexual activity, was
influenced by the menstrual function, and probably its ultimate cause would be
found in some disturbance of the nervous body which governed that function.
The presence of a myoma indefinitely delayed the menopause. Menstruation
and ovulation, he thought, were completely independent functions, having perhaps
a community of purpose. Removal of the ovaries often did not affect menstrua-
tion, but removal of the tubes nearly always did so. But in one case in which
he had removed the ovaries, tubes, and part of the fundus uteri, menstruation
continued for more than a year. Pie deprecated the triple subdivision of myomata
into submucous, intramural, and subperitoneal. For pathological and surgical
purposes, he proposed a new subdivision into the nodular and the concentric.
The latter consisted of a uniform hypertrophy of the muscular tissue of the
uterus, in the midst of which the canal lay centrally : the tissue of this form was
loose, and usually very edematous. Of the nodular myoma he proposed two
sub- varieties, the simple and the multinodular. He believed that each nodule
was seated in a central arterial twig, and that its growth was endogenous, the
older tissue being on the outside. The dependence of such growth on menstrua-
tion was proved by the fact that arrest of menstruation arrested the growth, or
even caused the complete disappearance, of such tumours. This had been in
several cases brought about by the removal of the Fallopian tubes only. He had
treated 54 cases of uterine myoma by removal of the uterine appendages, with
3 deaths, a mortality of 5.5 per cent., a striking contrast to the results of hyste-
rectomy. Of these 51, in 38 the results had been carefully followed, and were
everything that was to be desired. In 3, the tumours were, or became, malignant.
In 3 others, the tumours continued to grow, although menstruation had been
arrested. The author suspected that these were either fibro-cystic, or myoma of
the concentric variety, in neither of which forms was the removal of the uterine
appendages useful.

The President was hardly prepared to accept Mr. Tait's classification, but it
was not necessarily antagonistic to the one in common use. He agreed with Mr.
Tait as to the delay in the menopause in these cases. He would like further
evidence as to the sole or even large influence of the tubes in the phenomena of
menstruation.

Dr. Herman had published a case in which the symptoms of a fibroid polypus
first appeared sixteen years after the menopause. The history of patients after

1883.]

Midwifery and Gynaecology.

597

operations like those of Mr. Tait was of great importance, for patients not
benefited often did not return to the operator, and he therefore was apt to get a
too favourable impression of the results.

Dr. Dewar asked if Mr. Tait was careful to tie the uterine artery ; and whether
removal of the Fallopian tubes, leaving the ovaries, was not dangerous. He had
seen one case in which the uterine appendages had been removed, and hysterectomy
was subsequently required on account of hemorrhage.

Dr. Meadows preferred the present classification of fibroid growths to that
suggested by Mr. Tait, as being founded on clinical characters, and of great
practical value for diagnosis and treatment. He believed that the ovaries, and
not the tubes, were the prime movers in menstruation. In one case he had
removed the ovaries and left the tubes, and menstruation ceased. He thought
there were many exceptions to the rule that uterine fibromata ceased to grow
after the menopause. Notwithstanding the high rate of mortality which attended
hysterectomy, he preferred it to the removal of the ovaries.

Mr. Lawson Tait said that cases of growth of apparent uterine myomata
after the menopause needed most careful examination. Occasionally removal of
the ovaries arrested menstruation, but this was the exception. He had never
knowingly tied the uterine artery, and it would be very difficult to do so. —
British Med. Journal, July 21, 1883.

Accumulations of Pus in the Uterus.

Prof. N. F. Tolochinoff, of Kieff, describes that rare form of purulent
accumulation in the uterine cavity which is occasionally met in old women far
advanced in their climacteric period. This affection, references to which the
author could find only in English literature (Tilt, R. Barnes, Matthews Duncan,
Ashwell, Graily Hewitt), is characterized mainly by periodical discharge of
offensive pus through the os, which remains pervious to a sound. The introduc-
tion of the latter is always accompanied by the escape of purulent fluid from the
womb. The uterine cavity is invariably enlarged, its walls being more or less
thinned. The uterus at the level of the internal os is often retroflexed or ante-
flexed. The patients mostly complain of general weakness, and of constant or
periodical pains low down in the pelvis. The periodical increase of pelvic pain
coincides with the appearance of purulent discharge. The latter possesses very
irritating properties, giving rise to colpitis, distressing pruritus of the external
genitals, chronic eczema of the thighs, etc. Many of the patients present yel-
lowish pallor of the face.

Passing to the theory of these cases, Professor Tolochinoff comes to the conclu-
sion that the affection results from anterior catarrh of long standing. Any slight
obstruction (as caused by a flexion or initial cancerous consolidation of the cervical
tissues) to the escape of uterine discharge may lead to retention of the secretion,
with gradual distension of the thin walls of the atrophic senile womb. Under
the influence of the air which still can penetrate through the pervious os, the re-
tained catarrhal fluid undergoes decomposition, acting very irritatingly on the
mucous membrane, and producing ulceration with more or less abundant purulent
.secretion. (In the author's cases the quantity of pus discharged at a time was
not more than one or two tablespoonfuls ; but in Ashwell' s case it was about ten
ounces.)

The author details two of his cases of the affection in question, and the treat-
ment they underwent. In one of the cases, Duncan's intra-uterine injections of
nitrate of silver, Barnes's introduction of solid sulphate of zinc, and injections of
tincture of iodine and salicylic acid, brought only slight relief. The author de-
cided then to treat the uterine cavity as if it were an abscess. Accordingly, he

598

Progress of the Medical Sciences.

[Oct.

introduced an intra-uterine pessary in the shape of a silver drainage-tube and
daily washed the womb through it with one per cent, solution of carbolic acid.
A considerable improvement both of the local conditions and of the general
health followed. The occasional removal of the drainage-pessary was followed
within two or three weeks by the return of pelvic pains, purulent discharge, and
general symptoms. By the end of two years, complete recovery was seemingly
obtained : the. uterine cavity decreased from 8 to 6 centimetres ; the discharge
ceased, and did not reappear after taking out the intra-uterine tube. The other
patient is still under observation. — London Med. Record, July, 1883.

Puerperal Inversion of the Uterus.

Prof. Braux, of Vienna, reports in the Wiener Med. Blatter, Feb. 22, the
following interesting case, with remarks : A primapara, aat 20, well nourished,
but somewhat flabby and moderately plethoric, was delivered naturally of a
healthy male child, about five hours after the rupture of the membranes, at 3
A. M. on July 1. A few minutes later, without any traction having been
made on the umbilical cord, a bag of membranes filled with blood protruded
from the vulva and soon burst, discharging an enormous quantity of blood,
mostly fluid, followed immediately by the inverted uterus with the placenta
partly attached to its surface. The attendant, whose hand had been gently
rubbing the abdomen, felt it at the same time suddenly empty. The uterus
was replaced within the vulva, the placenta detaching itself in the process, and
taxis was applied with the flexor surface of the fingers of the left hand. The
right wall, corresponding to the pressure of the four fingers, was reduced first,
and the other followed at once. Friction was then applied to the uterine wall by
the right hand on the abdomen, against the left in the uterine cavity. Two quarts
of a 2 per cent, carbolic solution were injected into the uterus, followed by four
quarts of cold water, and subcutaneous injections of ergotin were employed. The
patient had lost more than 63 ounces of blood, had almost lost consciousness, and
was nearly pulseless. The lower extremities were, therefore, entirely enveloped
in elastic bandages, the hip raised, and ether injections, tea with rum, etc. ad-
ministered, until the pulse became moderately strong, and about 104 in the
minute. The temperature was not taken on account of the necessity of keeping
the patient warmly covered. Ice was placed on the abdomen, and no massage
employed, and the uterus contracted so well that five stools passed within the
twenty-four hours without causing any attempt at inversion. In spite of the free
administration of stimulants and fluid nourishment, by mouth and rectum, the
heart's action increased until on the evening of the second day the pulse was 152,
with a temperature of 97.16° F., and a disproportion between pulse and tempe-
rature was still present two weeks afterwards. The importance of the auto-trans-
fusion by means of the elastic bandages was shown by the subsequent history.
When they were only partially loosened on the thigh, after four hours, symptoms
of threatening collapse necessitated their re- application in a quarter of an hour;
the attempt some hours later to bandage an arm and set free one leg produced
dizziness, and the bandages could not be fully removed until after nineteen hours.

This case went on to complete involution of the uterus and usual health, and
shows the operation of complete atony of at least a portion of the uterus in the
production of inversion, which may then be induced even by the pressure of the
abdominal muscles, so that it is not necessary to refer it always to external influ-
ences. The blood liberated by the partial detachment of the placenta collects
between it and the uterine walls, flows into the membranes, and presses them
down to the vulva, out of which they protrude, the blood behind meanwhile

1883.]

Medical Jurisprudence and Toxicology.

599

dilating the lower segment of the uterus. The sudden bursting ofthe membranes
and escape of the blood causes the inversion of the distended uterus, a partial
inversion having probably already begun at the uncontracted seat of placental
attachment, which may have been aided by traction on the part of the mem-
branes.

Inversion is not so rare in primipara as has been imagined, and the following are
the causes of its production in them : —

1. Feebleness of uterine contractions from the length of the labour, even when
it is terminated by forceps, is the first cause.

2. Attachment of the placenta to the fundus, which is more common in primi-
parae, predisposes to inversion.

3. The tense vaginal walls do not give under the downward force, and there-
fore do not so easily prevent inversion.

4. The narrow vulva serves to hinder the outflow of the blood, and so facili-
tates inversion through distension, and subsequent sudden escape of the blood.

In multiparas, a predisposition to inversion maybe occasioned by adherent pla-
centa in previous labours. — Lond. Med. Record, July 15, 1883.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

Diffusion of Arsenic through the Body when thrown into the Mouth and
Rectum after Death.

A recent murder trial in Michigan has brought out some new facts regarding
the post-mortem diffusion of poisonous substances, which are substantially as
follows : After the death of a lady, whose symptoms strongly pointed to arsenic
poisoning, the husband, with a view of preserving the body for removal, injected
arsenic suspended in water into the mouth and rectum. He claims to have put
about a teaspoonful of arsenic into a teacupful of water, and to have injected one
syringeful into the mouth and two into the rectum. The syringe which he claims
to have used was an ordinary bulb syringe, with rectal tube attached.

One hundred and five days after her death the body was taken up, and the
stomach and rectum placed in one jar, and a piece of the liver and one kidney in
another; and the jars were sent to Prof. A. JB. Prescott for analysis of their
contents. Dr. Prescott found in the stomach and rectum together about twenty
grains of arsenious oxide, and from his analysis he calculated the amount in the
whole liver to be from six to fifteen grains, according to the size of that organ.
Later the body was again taken up, and the brain and a part of the muscles of
the calf of the leg sent to Prof. Prescott for analysis. In these he failed to find
any poison.

The question asked the experts, and the one which this paper considers, was :
"Granting that the arsenic was injected into the mouth and rectum in the manner
claimed, could it reach the liver and other organs outside the alimentary canal?"
This was the main question, and on it the experts were divided.

In order to determine this question, Drs. Vaughan and Dawson" made the
following experiments: A large musk-rat was killed, and about 50 grains (3.24
grammes) of arsenious oxide suspended in cold water were injected with an ordi-
nary bulb syringe with rectal tube attached into the mouth and rectum. The rat
was placed in a pine box and buried. After twenty-five days it was disinterred,
and the various organs removed and subjected to analysis.

600

Progress of the Medical Sciences.

[Oct.

The lungs contained a much larger amount of arsenic than the stomach. Evi-
dently the larger portion of that injected into the mouth passed down the trachea
instead of going down the oesophagus — indeed, the amount found in the liver is
larger than that found in the stomach. It is likely that the poison passed from
the lungs into the liver. The amount found in the brain is large, but in the
musk-rat the bones of the skull are thin in texture, and are not firmly united.

In the second experiment a cadaver was used. The person had been dead
between two and three days when the injection was made. An unweighed quan-
tity of arsenious oxide was suspended in cold water, and this was injected by
means of a common bulb syringe, with rectal tube, into the mouth and rectum.
The body was laid away in a dry cellar for twenty-five days. The various parts
of the body were then removed, weighed, and subjected to analysis. In dis-
secting the body, it was observed that, although the cuticle had decomposed to a
certain extent, the internal organs were firm to the touch, and remained in a
fair state of preservation. This was true of all the parts removed, except the
brain, which was broken down to a semi-fluid condition.

While the right kidney contained only an unweighable quantity, the left kidney
furnished nearly as large a per cent, of arsenic as was furnished by the liver. We
account for this by supposing that on the right side the liver caught up the greater
portion of the arsenic passing down from the right lung, while on the left side the
arsenic passed on more freely into the kidney. Contrary to what was observed
in the experiments on the musk-rat, the stomach of the cadaver contained a large
amount of arsenic, and it seems probable that some of the fluid thrown into the
mouth passed directly into the stomach. We were surprised at finding the arsenic
in the brain, and the query arises, by what avenue did the poison reach this organ ?
We noticed that, while throwing the fluid into the mouth at one time, when the
bulb of the syringe was very forcibly compressed, a portion of the fluid returned
through the nose. It is probable that some of the arsenic adhered to the roof of
the pharynx and along the nasal passages, and from thence penetrated the brain.

It will be seen from these experiments that the arsenic was quite as widely
diffused through the body as it would have been had it been administered during
life, and had it been the cause of death. These experiments also show that in a
case of suspected arsenical poisoning, if arsenic has been introduced into the
mouth and rectum in the manner above given after death, the finding of the
poison in the various organs mentioned will be no proof that the poison was
administered during life and caused death. Now, embalming fluids containing
arsenic are quite generally and indiscriminately used. They are used by the
physician, by the undertaker, and by others who prepare the body for burial.
Some throw the fluid into the mouth or rectum, or both ; some puncture the
abdominal walls with a trocar and then fill the cavity with the fluid ; others
simply bathe the body with some soluble form of arsenic, or cover the body with
cloths saturated with such a solution; others still inject a solution of arsenic into
an artery. The most weighty argument yet urged against cremation is that it
may be used as a means of covering up crime ; but in a case of arsenical poison-
ing the use of an arsenical embalming fluid may be employed as a more certain
method of covering up the crime than the incineration of the body would be= On
the other hand, as long as the present frequent use of these embalming fluids
continues, some innocent person may be accused of committing murder by arsenical
poisoning, and, arsenic being found in the body, may suffer an unjust sentence.

In all of these experiments, not only were "chemically pure" reagents used,
but these were thoroughly tested for arsenic. — Journ. of the American Med.
Assoc., Aug. 4, 1883.

INDEX.

Abdomen, hydatid tumours of, 506
Abdominal surgery, 509

wail, excision of, 274

Abnormalities observed at Guy's Hospital,
514

Abscess of iliac fossa, 463

, perisplenic, 266

Abscesses of neck causing sudden death,
321

Acetal and paraldehyde, 556
Acetonuria, 563
Aconitine poisoning, 516
Adenoma of kidney, 568
Albuminuria of Bright's, natm:e of, 570
, relation between serum-al-
bumen and globulin in, 572
Allen, Human Anatomy, review of, 229
Altounian, lithotomy statistics, 151
Amputation of hip, control of hemorrhage

after, 280
Anaemia, arsenic in, 576

, idiopathic, 515

Anaesthetic action of chloroform and mix-
ture of air, 555
Aneurism, galvano-puncture in, 447
Angiua pectoris, nitric and nitrous com-
pounds in, 262

, treatment of, 262

Angioma of scalp, removal by elastic liga-
ture, 271
Aortic valves, disease of, 503
Area, reflex of nose, 106
Arkansas, Health Report for 1882, review

of, 535
Arsenic in anaemia, 576

, post-mortem diffusion of, 597

Asthma, bronchial, pathology, 565
Atkinson, iodine in malarial fever, 63
Atlee, abscess of the left iliac fossa, 463

Bacteria, review of, 531
Barium chloride, physiological action of,
550

Belfield, micro-organisms and disease,
531

Bismuth treatment of wounds, 248, 249
Bladder and rectum, physiology of, 550
Bones, tarsal, removal in tabetic arthro-
pathy, 258

Brain and cord, contusions of, 31
Bright's disease, albuminuria of, 570
Bronchial glands, enlargement of, 125
Bruen, enlarged bronchial glands and

pneumograstic irritation, 125
Burr on primary monomania, 93

Caesarean, Porro-, classification, 430

, operation, 477

Calculous affections of pancreatic ducts,
404

Carotid, ligation of, 282
Cathartics, saline, action of, 551
Chambers, galvano-puncture in aneurism,
447

Chatin, La Trichine et la Trichinose, re-
view of, 227
Chloroform and air, mixture of, as anaes-
thetic, 555
Chloroma, 287
Cholera, treatment of, 561
Chyluria and haemato-chyluria, 573
Ciliary weakness, eserine in, 586
Cinchonide, physiological effects of, 243
Circulation of kidney during fever, 380
Cohen, immobility of one vocal band, 84
Cohn on Bacteria, review of, 531
Colon, percussion of, in diarrhoea, 267
Coma, diabetic, 563

, uraemic, and of cerebral hemor-
rhage, 251

Concussion, spinal, 493

Connecticut, Report of the State Board of
Health for 1882, review of, 210

Conner, on excisions of the tarsus, 362

Constipation, habitual, 266

Cord, contusions of brain and, 31

Corpora striata, symmetrical softening of,
513

Cough, nasal, 106

Coxalgia, subcutaneous osteotomy in, 101
Croup and diphtheria, tracheotomy, 272
Cystotomy after nephrectomy, 275
Cysts of kidneys drained, with ovariotomy,
292

Diabetes in children, 561

, puerperal, 196

Diabetic coma, 563

602 Ind

Diarrhoea, percussion of colon in diagnosis
of, 267

Diphtheria and croup, tracheotomy in, 272
Disease germs, 531

Dispensatory, United States, review of, 215
Distoma haematobium, alterations pro-
duced by, 268
Duhring, Paget's disease of nipple, 116
Duodenum, ulcer of, 579
Dysmenorrhoea, 194, 591

Emmet's operation, 193
Emphysema after whooping-cough, 147
Empyema, removal of portion of rib in,
513

Enchondromata of salivary glands, 515
Enteric fever, 505

, analysis of 31 cases, 505

, erythematous eruption in,

250

Erb, Electro-therapeutics, review of, 545
Ergotinine, in post-partum hemorrhage,
197

Erysipelas, micrococcus of, 253
Eserine in ciliary weakness, 586
Eucalyptus steam in infectious diseases,
244

Excision of abdominal wall, 274
F.

Fecal retention, 506

Fenwick, excision of knee-joint, 538

Fever, circulation of kidney during, 380

, resorcin in, 558

Fibroma of round ligament, 295
Fischer, Das Naphthalin, review of, 237
Fletcher, experiments on serpent venom,
131

Galvano-puncture in aneurism, 447
Gaingee on Wounds and Fractures, review
of, 540

Gangrene, tachetic symmetrical, 255
Germs, disease, 531
Goitre, excision of, 532

, exophthalmic, mental disorders in,

513

Gradle on Bacteria, review of, 531
Grant on an anomaly of the heart, 149
Gray's Anatomy, review of, 516
Grossmann, a modified Porro- Cesarean

operation, 4T7
Guy's Hospital Reports, review of, 512
Gjmecology, sharp spoon in, 295

Hemaglobinemia, 559
Hemato-chyluria and chyluria, 573
Hair tumour in abdomen, 279
Hamilton, Types of InsanuVv, review of, 540
Hammond on Insanity, review of, 521
Harris, classification of the Porro opera-
tions, 430

Harrison on Lithotomy, Lithotrity, etc.,

review of, 545
Hay on action of saline cathartics, 551
Health Reports, review of, 210
Heart, anomaly of, 149
Heart, tricelian, 505

EX.

Hemianesthesia, 515

Hemorrhage after placenta previa, 289

by vaso- motor irritation. 213

, control of, in hip amputation,

Lloyd, 280

, fatal, from rectal nevus, 279

, post-partum, ergotinine in,

197

Hernia, inguino-properitoneal, 584
Hoffman and Power, Chemical Analysis,

review of. 235
Holmes, Medical Essays, review of, 219
Hospital Reports, Guy's, review of, 512
, St. Thomas's, review of,

503

Hydatid tumours of abdomen, 506
Hyde, Diseases of the Skin, review of, 222
Hygiene, review on, 206
Hyoscyamia in psychiatric practice, 55^

Iliac fossa, abscess of, 463
Infectious diseases, eucalyptus steam in,
244

Inhalations in pulmonary disease, 260
Intestine, resection of, 278
Intraperitoneal injections in poisoning, 296
Iodine in malarial fevers, 63
Iodoform, 554

in chronic pulmonary disease,

261

James, Sore Throat, review of, 240
Jaws, closure of, treatment, 454
Jenckes on radical cure of varicocele, 153
Jennings, Transfusion, review of, 233
Johnson on calculi of the pancreatic ducts,
404

Keratitis, experimental, 120
Kidney, adenoma of, 568

, circulation of during fever, 380

, cysts of, drainage, 292

, fatty transformation of, 567

, tumour of, removal, 5S5

Knee, excision of, 538

, resection of, 286

Kymographic measurements in man, 549

Lead poisoning, lunacy in, 515

Leprosy, treatment of, 574

Leueoderma, 269

Lidell, abscesses of neck, 321

, contusions of brain and cord, 31

Liebrecht, excision of goitre, review of. 532

Ligation by two ligatures and division of
vessel between them, 281

Lithotomy statistics, 151

Liver, partial regeneration of, 241

Lunacy, saturnine, 515

Luug, emphysema and abscess of, after per-
tussis, 147

Lungs, operative procedures on, 588

Lymphatic system, primary radicles of, 547

Mackenzie on reflex nasal cough, 106
Magnin, The Bacteria, review of, 531

Ini

Maguire on The Bacteria, review, 531

Malarial fevers, iodine in, 63

McKay on otorrhoea with perforation of

merabrana tympani, 468
Mears on closure of the jaws, 454
Medical and Surgical History of the War

of the Rebellion, review of, 155
Medieo-Chirurgical Society of Edinburgh,

Transactions, review of, 529
Melituria after scarlatina, 563
Mendelson, renal circulation during fever,

380

Meningitis, ataxic, nerve stretching in, 508
Mental disorders in exophthalmic goitre,
513

Metria, 299, 588

Michel, ligation of the subclavian, 439
Michigan T Health Report for 1832, review
of, 210

Micrococcus of erysipelas, 253
Minor on experimental keratitis, 120

the field of vision, 77

Mitchell on lesions of nerve-trunks, 17
Monomania, primary, 93
Morison on the prurigo papule, 341
Myoma, uterine, pathology and treatment,
596

Nsevus of rectum, fatal hemorrhage, 279
Naphthalin, review of, 237
Naphtol in skin diseases, 479
Nasal cough, 106

Nav}~, Sanitary and Statistical Report of
the Surgeon-General of, for 1881, review
of, 517

Neck, abscess of, causing sudden death,
321

, pulsating tumour at root of, 514

Nephrectomy, 276

, cystotomy after, 275

for rupture of kidney, 275

Nerve stretching, Ceccherelli, 283

in ataxic meningitis, 508

Nerve-trunks, lesions of peripheral, 17
Nettleship, Diseases of the Eye, review of,
239

New Hampshire, Health Report for 1882,
review of, 535

New Jersev. Report of the State Board of
Health, for 1882, review of, 210

Nipple, Paget's disease of, 116

Nitro-glycerine, therapeutic use of, 246

Northrup, emphysema after whooping-
cough, 147

Nose cough, 106

, reflex area of, 106

Obstetrical Society of London, Transac-
tions, review of, 193

(Esophagus, primary stenosis, 259

Ontario, Report of Board of Health for
1882, review of, 210

Osteotomy in coxalgia, 101

Otorrhoea, clinical observations on, 468

Ovarian tumours, solid, propriety of ope-
rating, 293

Ovariotomy and drainage of renal cysts,
292

ex. 603
P. '

Page, Spinal Concussion, review of, 493
Paget's disease of nipple, 116
Pancreatic ducts, calculous affections of,
404

Paraldehyde, acetal and, 556

Parkes, Practical Hygiene, review of, 206

Pericarditis, purulent, free incision, 263

Perisplenic abscess, 266

Pertussis, emphysema after, 147

, resorcin in, 5(31

Petrous bone, trephining, 587
Phosphorus poisoning, oil of turpentine

in, 513
Piperidin, action of, 553
Placenta prsevia, treatment of, 288
post-partum

hemorrhage in, 289
Pneumogastric irritation from enlarged

bronchial glands, 125
Poisoning by aconitine, 516
Politzer, Diseases of the Ear, review of,

220

Porro-Caesarean operation, modified, 477

operations, classification of, 430

Pregnancy, complicated by cancer of
uterus, 197

, extra-uterine, 588

, interstitial, 196

, tubo-uterine, 196

Prurigo papule, study of, 341
Puerperal diabetes, 196
Purpura, hemorrhage of nerve centres, 255
Pyrexia, paroxysmal, simulating ague, 504

Quain, Anatomy, review of, 232
R.

Rectum, hemorrhage in nasvus of, 279

, physiology of bladder and, 550

Reflex nasal cough, 106
Renal tumour, removal, 585
Resection of intestine, 278, 583, 584

of knee, 286

of wrist, 286

Resections, subperiosteal, 284
Resorcin in fevers, 558

in pertussis, 564

Reviews —

Allen, System of Human Anatomy,
229

Annual Report of Medical Officer of
Local Goverment Board, London,
1881 , 190

Arkansas, Health Report for 1882,
535

Belfield, Relations of Micro-organisms

to Disease, 531
Chatin, La Trichine et la Trichinose,

227

Cohn, Bacteria, 531
Connecticut, Health Report for 18S2,
210

Dispensatory of United States, 215
Erb, Handbook of Electro- Therapeu-
tics, 515

Fenwick, Excision of Knee-joint, 538
Fischer, Das Naphthalin. 237
Gamgee on Wounds and Fractures,
540

604

Index

Reviews —

Gradle, Bacteria and the Germ The-
ory, 531

Gray, Anatomy, 546

Guy's Hospital Reports, 512

Hamilton, Types of Insanity, 540

Hammond on Insanity, 521

Harrison on Lithotomy, Lithotrity,
etc. 545

Health Reports, 210, 535

Hoffman & Power, Chemical Analysis,
235

Holmes, Medical Essays, 219
Hyde, Diseases of the Skin, 222
James, Sore Throat, 240
Jennings, Transfusion, 233
Liebrecht, Excision du Goitre Paren-

chymateux, 532
Magnin, The Bacteria, 531
Medical and Surgical History of War

of Rebellion, 155
Michigan, Health Report of, for 1882,

210

Nettleship, Guide to Diseases of the
Eye, 230

New Hampshire, Health Report for
1882, 535

New Jersey, Health Report for 1882,
210

Ontario, Health Report of, for 1882.
210

Page on Spinal Concussion, 493
Parkes, Practical Hygiene, 206
Politzer, Diseases of the Ear, 220
Quain, Elements of Anatomy, 232
Rhode Island, Health Report for 1882,
535

Saint -Germain, Chirurgie Orthope-

dique, 525
St. Thomas's Hospital Reports, 503
Sanitary and Statistical Report of the

Surgeon-General of the Navy for

1881, 517

Sattler, History of Tuberculosis, 530
Sayre, Orthopaedic Surgery, 203;
Stimson, Treatise on Fractures, 197
Tait, Diseases of the Ovaries, 172
Transactions of Obstetrical Society of

London, 193
Transactions of the Medico-Chirurgi-

cal Society of Edinburgh, 529
Ziegler, Pathological Anatomy and

Pathology, 527
Rib, removal of portion of, in empyema,
513

Saint-Germain, Chirurgie Orthopedique,

review of, 525
Saline cathartics, action of, 551
Sattler, History of Tuberculosis, review of,

530

Sayre, Orthopaedic Surgery, review of, 203

Scalp, angioma of, 271

Scarlatina and melituria, 562

Semmola on primary radicles of lymphatic

system, 547
Septa in vagina, 196
Serpent venom, experiments on, 131
Skin, Diseases of, review on, 222
Skin-flaps, transplantation of, 270
Sorethroat, James on, review of, 240

Spinal concussion, 493

Spleen, healing of wounds of, 275

Splenic, peri-, abscess, 266

, contusion, 31

Spoon, sharp, in gynaecology, 295
Staining, materials for, 516
Stimson, Treatise on Fractures, review of,
198

Stimulants, subcutaneous injection of, 246
Subclavian, ligation of, 439
Surgery, orthopaedic, review of, 203

Tabetic arthropathy, removal of tarsal

bones in, 258
Tait, Diseases of Ovaries, review of, 172
Tarsus, excisions of, 362
Tongue, surgical affections of, 514
Trachelorrhaphy, 193

Tracheotomy in croup and diphtheria, 272
Transfusion, review on, 233
Trephining the pyramid of petrous bone,
587

Trichinosis, review on, 227
Tuberculosis, review on, 530
Tubo-uterine gestation, 196
Tumor, pulsating, at root of neck, 514

, renal, removal of, 585

Turpentine, oil of, in phosphorus poison-
ing, 513

Typhoid fever, renal form of, 560
U.

Ulceration, catarrhal, 260

Urine ferments and fermentation, 242

, new crystalline and colouring mat-
ter in, 242

Uterine appendages, removal of, 195

, myoma, 596

Uterus, ablation of, 195

, epithelioma of, complicating preg-
nancy, 197

Vaccination during pregnancy. 291
Vagina, transverse septa in, 196
Valves, aortic, diseases of, 503
Van Harliugen, naphtol in skin diseases,
479

Varicocele, radical cure, 153
Vaseline in obstetrics, 291
Veratrine, physiological effects of, 243
Vision, field of, 77

, new centre of, 548

Vocal bands, immovability of, 84

Wharton, osteotomy in coxalgia, 101
Whooping-cough, emphysema after, 147

, resorcin in, 564

Wood & Bache, United States Dispensa-
tory, review of, 215
Woods, iodine in malarial fever, 63
Wounds, bismuth treatment of, 24S, 249

■, Gamgee on treatment of, 540

Wrist, resection of, 286

Ziesler, Pathological Anatomy, review of,
527

American Journal of the Medical Sciences. 605

BELLETUE HOSPITAL MEDICAL COLLEGE,

CITY OF NEW YORK.

SESSIONS OF 1883-84.

The standard of Medical Ethics recognized by the College is embodied in the Code
of Ethics of the American Medical Association.

The Collegiate Tear embraces the Regular "Winter Session and a Spring Session.

The Regular Session begins on Wednesday, September 19, 1883, and ends about the

middle of March, ISSi. During this Session, in addition to the regular didactic lectures,

two or three hours are daily allotted to clinical instruction. Attendance upon two

regular courses of lectures is required for graduation. The Spring Sessiox consists

chiefly of recitations from Text-Books. This Session begins about the middle of March,

and continues until the middle of June. During this Session, daily recitations in all

the departments are held by a corps of Examiners appointed by the Faculty. Short

courses of lectures are given on special subjects, and regular clinics are held in the

Hospital and in the College building.

FACULTY.

ISAAC E. TAYLOR, M.D.,
Emeritus Prof, of Obstetrics and Diseases or Womeu and Children, and President of the Faculty.

PORDYCB BARKER, M.D., LL.D.,
Professor of Clinical Midwifery and Diseases
of Women.
AUSTIN FLINT, M.D. .LL.D.,
Prof, of the Principles and Practice of Medicine,
and Clinical Medicine.

BENJAMIN W. McCREADY. M.D.,
Emeritus Professor of Materia Medica and
Therapeutics.
A. A. SMITH, M.D.,
Professor of Materia Medica and Therapeutics,
and Clinical Medicine.
AUSTIN FLINT, Jr , M.D.,
Professor of Physiology and Physiological
Anatomy, and Secretary of the Faculty.
JOSEPH D. BRYANT, M.D.,
Professor of Anatomy and Clinical Surgery, and
Associate Professor of Orthopedic Surgery.
R. OGDEN DOREMUS, M.D , LL.D.,
Professor of Chemistry and Toxicology.
EDWARD G. JAXEWAY, M.D.,
Prof, of Diseases of the A'ervous System, and
Clinical Medicine, and Associate Professor
of Principles and Practice of Medicine.

FREDERICK S. DENNIS, M.D.,
Professor of Principles and Practice of Surgery
and Clinical Surgery.

LEWIS A. SAYRE. M.D.,
Professor of Orthopedic Surgery aud Clinical
Surgery.
ALEXANDER B. MOTT. M.D.,
Professor of Clinical and Operative Surgery.
. WILLIAM T. LUSK, M.D.,
Professor of Obstetrics and Diseases of Women
and Children, and Clinical Midwifery.

PROFESSORS OF" SPECIAL DEPARTMENTS, Etc.

J. LEWIS SMITH, M.D.,
Clinical Professor of Diseases of Children.
BEVERLY ROBINSON, M.D.,
Clinical Professor of Medicine.
FRANCKE H. BOSWORTH, M.D.,
JOHN P. GRAY, M.D., LL.D.. Professor of Diseases of the Throat.

Professor of Psychological Medicine and Medical CHARLES A. DORE1IUS, M.D. , Ph.D.,

Jurisprudence. Professor Adjunct to the Chair of Chemistry and

WILLIAM H. WELCH, M.D., Toxicology,
Professor of Pathological Anatomy and WILLIAM H. WELCH, M.J).,

General Pathology. Demonstrator of Anatomy.

FEES FOR THE REGULAR SESSION.

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Fees for Tickets to all the Lectures, Clinical and Didactic

Fees for Students -who have attended two full courses at other Medical Colleges, and ;

for Graduates of other Medical Colleges . - J

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Jio Fees for Lectures are required of third course Students -who have attended thei

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For the Annual Circular and Catalogue, giving regulations for graduation and other informa-
tion, address Prof. Austin Flint, Jr., Secretary, Bellevue Hospital Medical College.

60G

American Journal of the Medical Sciences.

MEDICAL DEPARTMENT OF THE UNIVERSITY OF
LOUISIANA — NEW ORLEANS.

FACULTY.

T. G. RICHARDSON, M.D.,
Professor of General and Clinical Surgery.

SAMUEL M. BEMISS, M D.,
Professor of the Theory and Practice of
Medicine and Clinical Medicine

STANFORD E. CHAILLE, M.D.,
Prof, of Physiology and Patholog. Anatomy.

JOSEPH JONES, M D ,
Prof, of Chemistry and Clinical Medicine.

SAMUEL LOGAN, M.D,
Professor of Anatomy and Clinical Surgery.

ERNEST S. LEWIS. M.D.,
Professor of General and Clinical Obstetrics
and Diseases of Women and Children.

JOHN B. ELLIOTT, M.D ,

Professor of Materia Medica and
Therapeutics and Hygiene.

Lecturer on Diseases of the Eye

ALBERT B. MILES, M.D.,
Demonstrator of Anatomy.

The next'annual course of instruction in this Department (now in the fiftieth year of its
existence) will commense on Monday, the 2'2d day of October, 1S83, and terminate on
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The Act establishing the University of Louisiana gives the professors of the Medical
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The regular lectures at the hospital, on Clinical Medicine by Professors Bemiss and
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TERMS.

For the Tickets of all the Prof ssors ... . $140 00

For the Ticket of Practical Anatomy .... . 10 00

Matriculation Fee . . . . . . 5 00

Graduation Fees . . . . . . 30 00

Candidates for graduates are required to be twenty-one years of age ; to have studied
three years : to have attended two courses of lectures, and to pass a satisfactory examina-
tion.*

T. G. RICHARDSON, M.D., Dean.
* For further information upon these points see circular.

American Journal of the Medical Sciences.

607

THE

JEFFERSON MEDICAL COLLEGE

OF PHILADELPHIA.

The Fifty-ninth Session of the Jefferson Medical College will begin on Monday,
October 1st, 1883, and will continue until the end of March, 1884. Preliminary Lectures
will be held from Monday, 11th of September.

PROFESSORS.

S. D. GROSS, M.D., LL.D., D.C.L. Oxon.,
LL.D. Cantab. (Emeritus).
Institutes and Practice of Surgery.
ELLERSLIE WALLACE, M.D. (Emeritus).
Obstetrics and Diseases of Women and
Children.

J. M. DA COSTA, M.D.,
Practice of Medicine.
WM. H. PANCOAST, M.D.,
General, Descriptive, and Surgical Anatomy.
ROBERT E. ROGERS, M.D.,
Medical Chemistry and Toxicology.
ROBERTS BARTHOLOW, M.D , LL.D..
Materia Medica and General Therapeutics.

HENRY C. CHAPMAN, M.D ,
Institutes of Medicine and Medical
Jurisprudence.

SAMUEL W. GROSS, M.D,
Principles of Surgery and Clinical Surgery.

JOHN H. BRINTON, M.D.,
Practice of Surgery and Clinical Surgery.

THEOPHILUS PARVIN, M.D., LL.D.,
Obstetrics and Diseases of Women and
Children

WILLIAM THOMSON, M.D.
Professor of Ophthalmology.

To the usual course of instruction in medical schools, the Medical Faculty of this
College have added a thorough system of practical Laboratory work. To each course
of the regular curriculum there is appended a Laboratory Course, carried on in large
and thoroughly equipped apartments in the College, by specially appointed Demonstra-
tors, under the immediate direction of the Professor. In this way each candidate for the
degree of M.D. is immediately and personally taught in Obstetrics and GynaBCology,
Physical Diagnosis, Laryngology, Ophthalmology, Medical Chemistry, Pharmacy, Materia
Medica and Experimental Therapeutics, Physiologj', Histology and Experimental
Physiology, and Minor Surgery, Bandaging, Operations on the Cadaver, etc. In the
Department of Medicine, "clinical conferences,'' and practical lessons in Physical
Diagnosis, give each student familiarity with .til forms of disease. The experience of
several Sessions has abundantly demonstrated the great value of this Practical Teaching.

A Spring Course of Lectures is given, beginning early in April, and ending early in
June. There is no additional charge for this Course to matriculates of the College, ex-
cept a registration fee of five dollars; non-matriculates pay forty dollars, thirty five of
which, however, are credited on the amount of fees j)aid for the ensuing Winter Course.

A Post Graduate Course, very complete in all the details of instruction, has been
organized for practitioners only.

CLINICAL INSTRUCTION is given daily at the HOSPITAL OF THE JEFFERSON
MEDICAL COLLEGE throughout the year by Members of the Faculty, and by the Hos-
pital Staff.

FEES.

Matriculation Fee (paid once) $5 00 j Practical Anatomy $10 00

Ticket for each Branch (7) $20 140 00 I Graduation Fee 30 00

Fees for a full course of Lectures to those who have attended two full courses at

other (recognized) Colleges — the matriculation fee, and $70 00

The Annual Announcement, giving full particulars, will be sent on application to

ROBERTS BARTHOLOW M.D., Dean.

608 American Journal of the Medical Sciences.

UNIVERSITY OF THE CITY OF NEW YORK,

MEDICAL DEPARTMENT.

410 East Twenty-sixth St.,opp. J}rllevne Hospital, Xeiv TorJi City.
FORTY- THIRD SESSION, 1883-84.

FACULTY OF MEDICINE.

Rev. JOHN HALL, D.D., LL.D., Chancellor of the University, pro tern.
ALFRED C. POST, M.D., LL.D., Professor i LEWIS A. STIMSON. M.D., Professor of Pbysio-
Emeritus of Clinical Surgery; President of i logy and Physiological Anatomy; Surgeon to
the Faculty. Bellevue Hospital ; Curator to Bellevue Hos-

CHARLES INSLEE PARDEE, M.D., Dean of | Pital-

FANEUIL D. WEISSE. M.D., Professor of Prac-
tical and Surgical Anatomy ; Suigeon to Work-

the Faculty ; Professor of Otology ; Surgeon

to the Manhattan Eye and Ear Hospital.
J. W. S. ARNOLD, M.D., Emeritus Professor of house Hospital, B. I.

Physiology and Histology. i
TnH„ f, n,,.PVp urn ttti PMfM.n.«f STEPHEN SMITH. M.D., Professor of Cliuical
JOHN C. DRAPER, M.D., LL.D., Professor of a,,,™™ . k„h„„„„ un[.ni(„i

Chemistry.

Surgery ; Surgeon to Bellevue Hospital.

ALFRED L. LOOMIS, M.D., Professor of Patho- A. E. MACDONALD, LL.B., M.D., Professor of
logv and Practice of Medicine ; Visiting Phy- Medical Jurisprudence and Diseases of the
sician to Bellevue Hospital. , Mind: Medical Superintendent of the New

WM. DARLING, M.D., LL.D., F R.C.S., Pro- ■ York CUy Asylum for th° Insane'
fessor of General and Descriptive Anatomy. R. A. WITTHAUS, M.D., Professor of Physio-

WILLIAM H. THOMSON, M.D., Professor of ! logical Chemistry.

HERMAN KNAPP, M.D., Professor of Ophthal-
mology ; Surgeon to the Ophthalmic Iusiimte.

Materia Medica, Therapeutics and Diseases of
the Nervous System ; Visiting Physician to
Bellevue Hospital.

J. WILLISTON WRIGHT, M.D., Professor of s- OAKLEY VANDERPOBL, M.D., LL.D., Pro-
Surgery ; Visiting Surgeon to Bellevue Hos- fes.-or of Public Hygiene.

Pital. AMBROSE L. KANNEY, M.D., Curator of Mu-

WM. M. Polk, M.D., Professor of Obstetrics : senm.
and the Diseases of Women and Children; j JOSEPH E. WINTERS, M.D., Demonstrator of
Gynaecologist to Bellevue Hospital. 1 Anatomy.

ADJUNCT LECTURERS.

F. R. S. DRAKE, M.D., Clinical Lecturer on JOSEPH E. WINTERS, M D., Clinical Lecturer

Practice of Medicine; Visiting Physician to on Diseases of Children.
Bellevue Hospital.

N. M. SHAFFER, M.D., Clinical Lecturer on I WILLIAM C. JARYIS, M.D., Clinical Lecturer

Orthopaedic Surgery; Surgeon in Charge of on Laryngology.

the N. Y. Orthopaedic Hospital.
P. A. MORROW, M.D. Clinical Lecturer on LAWRENCE JOHNSON, M.D., Lecturer on

Dermatology. Medical Botany.

THE PRELIMINARY SESSION will begin on Wednesday, September 10, 1S83, and end October
3, 1SS3. It will be conducted on the same plan as the Regular Winter Session.

THE REGULAR WINTER SESSION will begin October 3, 1SS3, and end about the middle of
March, 18S1. The Plan of Instruction consists of Didactic and Clinical Lectures, recitations and
laboratory work in all subjects in which it is practicable. To put the laboratories on a proper
footing a new building has been erected at an expense of thirty-five thousand doliars. it will
contain laboratories fitted for instruction in Chemistry, Histology, Pathology, Materia Medica,
Operative Surgery and Gynaecology.

Two to five Didactic lectures and two or more Clinical lectures will be given each day by members
of the Faculty. In addition to the ordinary clinics, special clinical instruction, without additional
expense will be given to the candidates for graduation during the whole Regular Session. For
this purpose the candidates will be divided into sections of twenty-live members each. At these
special clinics students will have excellent opportunities to make and verify diagnoses, and watch
the effects of treatment. They will be held in the Wards of the Hospitals and at the Public and
College Dispensaries.

Each of the seven professors of the Regular Faculty will conduct a recitation on his subject one
evening each week. Students are thus enable ! to make up for lost lectures, and prepare them-
selves properly for their final examinations without additional expense.

THE SPRING SESSION will begin about the middle of March and end the last week in May.
The daily Clinics and Special Practical Courses will be the same as in the Winter Session, and
there will be Lectures on Special Subjects bv the Members of the Faculty. It is supplementary
to the Regular Winter Session. Nine months of continued instruction are thus secured to all
students of the University who de?ire a thorough course.

FEES.

For course of Lectures $140 00

Matriculation - ° 00

Demonstrator's Fee, including material for dissection 10 00

Final Examination Fee 30 00

For further particulars and circulars address the Dean,

Prof. CHAS. INSLEE PARDEE, M.D.,
University Medical College, 410 East 26th St., New York City.

Date Due

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